Provider Demographics
NPI:1073078705
Name:STATEN HALL, KRISTIN ASHLIE (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ASHLIE
Last Name:STATEN HALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:ASHLIE
Other - Last Name:STATEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7343 SAINT THOMAS LOOP
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-7116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1125 6TH ST SE
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4675
Practice Address - Country:US
Practice Address - Phone:320-235-4613
Practice Address - Fax:855-625-7406
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040107761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical