Provider Demographics
NPI:1497000319
Name:THERAPIST WILMINGTON
Entity Type:Organization
Organization Name:THERAPIST WILMINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW PHD
Authorized Official - Phone:910-795-6677
Mailing Address - Street 1:9404 VOYAGERS WAY
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-3442
Mailing Address - Country:US
Mailing Address - Phone:910-795-6677
Mailing Address - Fax:
Practice Address - Street 1:9404 VOYAGERS WAY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-3442
Practice Address - Country:US
Practice Address - Phone:910-795-6677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC005936101Y00000X, 101YA0400X, 101YM0800X, 102L00000X, 103K00000X, 104100000X, 1041C0700X, 1041S0200X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty