Provider Demographics
NPI:1205825544
Name:HALL, JOHN WESLEY (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WESLEY
Last Name:HALL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3337
Mailing Address - Country:US
Mailing Address - Phone:704-258-5553
Mailing Address - Fax:
Practice Address - Street 1:2157 MCCLINTOCK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5141
Practice Address - Country:US
Practice Address - Phone:704-258-5553
Practice Address - Fax:704-344-0078
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2457103TH0004X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000513Medicaid
225447000OtherMAGELLAN BEHAVIORAL HEALT
60054OtherAETNA PIN