Provider Demographics
NPI:1114407392
Name:HALL, TINA MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:HALL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 HERNDON ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4859
Mailing Address - Country:US
Mailing Address - Phone:318-205-8989
Mailing Address - Fax:
Practice Address - Street 1:458 HERNDON ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4859
Practice Address - Country:US
Practice Address - Phone:318-205-8989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
LA7573101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator