Provider Demographics
NPI:1760168793
Name:HALL, CARLTON DAVID JR (MDIV)
Entity Type:Individual
Prefix:
First Name:CARLTON
Middle Name:DAVID
Last Name:HALL
Suffix:JR
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 IVY LN
Mailing Address - Street 2:
Mailing Address - City:HEWITT
Mailing Address - State:TX
Mailing Address - Zip Code:76643-3436
Mailing Address - Country:US
Mailing Address - Phone:254-715-1635
Mailing Address - Fax:
Practice Address - Street 1:2210 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76701-1019
Practice Address - Country:US
Practice Address - Phone:254-274-3554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64375101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)