Provider Demographics
NPI:1902172471
Name:GLACE-HALL, ELIZABETH GRACE
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:GRACE
Last Name:GLACE-HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:GRACE
Other - Last Name:GLACE-HALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:10579 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4625
Mailing Address - Country:US
Mailing Address - Phone:718-629-2737
Mailing Address - Fax:
Practice Address - Street 1:1070 E 83RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4226
Practice Address - Country:US
Practice Address - Phone:718-241-5757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007535-1171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor