Provider Demographics
NPI:1174986947
Name:HALL, KEON
Entity type:Individual
Prefix:
First Name:KEON
Middle Name:
Last Name:HALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 FARNHAM AVE
Mailing Address - Street 2:
Mailing Address - City:INDIAN ORCHARD
Mailing Address - State:MA
Mailing Address - Zip Code:01151-1946
Mailing Address - Country:US
Mailing Address - Phone:646-851-5878
Mailing Address - Fax:
Practice Address - Street 1:3036 E TREMONT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5733
Practice Address - Country:US
Practice Address - Phone:718-823-3190
Practice Address - Fax:718-829-6667
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NY020478-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty