Provider Demographics
NPI:1619381084
Name:HALL, THERESSA
Entity Type:Individual
Prefix:
First Name:THERESSA
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 NW 122ND ST
Mailing Address - Street 2:APT 71
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8493
Mailing Address - Country:US
Mailing Address - Phone:405-209-2398
Mailing Address - Fax:
Practice Address - Street 1:1330 N. CLASSEN BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106
Practice Address - Country:US
Practice Address - Phone:405-555-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator