Provider Demographics
NPI:1215557731
Name:HALL, CORY JUSTIN (LMFT)
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:JUSTIN
Last Name:HALL
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TX
Mailing Address - Zip Code:79556-4719
Mailing Address - Country:US
Mailing Address - Phone:325-246-9121
Mailing Address - Fax:
Practice Address - Street 1:1219 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TX
Practice Address - Zip Code:79556-4719
Practice Address - Country:US
Practice Address - Phone:325-246-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15146101Y00000X, 101YA0400X
TX203092106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4314676Medicaid