Provider Demographics
NPI:1275756405
Name:HALL, PATRICIA ANN MARIE (LADC, CM)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:ANN MARIE
Last Name:HALL
Suffix:
Gender:F
Credentials:LADC, CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 369
Mailing Address - Street 2:
Mailing Address - City:TONKAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74653
Mailing Address - Country:US
Mailing Address - Phone:580-628-2539
Mailing Address - Fax:580-628-4316
Practice Address - Street 1:1608 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:TONKAWA
Practice Address - State:OK
Practice Address - Zip Code:74653
Practice Address - Country:US
Practice Address - Phone:580-628-2539
Practice Address - Fax:580-628-4316
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK924101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator