Basic Information
| Provider Information | |||||||||
| NPI: | 1750612545 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | DEVAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | MS, CM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8002 NW MICKLEGATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805361490 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 807 SW F AVE | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805957000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2010 | ||||||||
| LastUpdateDate: | 01/19/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | 20698 | OK | N | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.