Basic Information
| Provider Information | |||||||||
| NPI: | 1063762243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCAS, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2312B SADLER DR | ||||||||
| Address2: | |||||||||
| City: | WINTERVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285909868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199227924 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2245 STANTONSBURG RD, SUITE O | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527520483 | ||||||||
| FaxNumber: | 2527522971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2012 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 2907 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 2907 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.