Provider Demographics
NPI:1710532411
Name:HALL, JUSTIN D (COTA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:D
Last Name:HALL
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1738 N 77 SUNSHINESTRIP
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-4255
Mailing Address - Country:US
Mailing Address - Phone:956-744-0096
Mailing Address - Fax:
Practice Address - Street 1:1525 E 6TH ST STE B
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-4667
Practice Address - Country:US
Practice Address - Phone:956-969-9400
Practice Address - Fax:956-969-9411
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212850224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX262858905Medicaid