Provider Demographics
NPI:1548790819
Name:HALL, JOHN
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:HALL
Suffix:
Gender:M
Credentials:
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 7473 PORT ST. LUCIE FL
Mailing Address - Street 2:2373 SE. SURREY PL. PORT ST. LUCIE FL
Mailing Address - City:PORT ST. LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34985
Mailing Address - Country:US
Mailing Address - Phone:772-267-1158
Mailing Address - Fax:
Practice Address - Street 1:2373 SE SURREY PL
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7360
Practice Address - Country:US
Practice Address - Phone:772-267-1158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician