Provider Demographics
NPI:1902360662
Name:HALL, MATTHEW EARET (COTA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EARET
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:PO BOX 1525
Mailing Address - Street 2:
Mailing Address - City:MEXIA
Mailing Address - State:TX
Mailing Address - Zip Code:76667-1525
Mailing Address - Country:US
Mailing Address - Phone:254-625-0361
Mailing Address - Fax:
Practice Address - Street 1:1010 DALLAS ST
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76704-1711
Practice Address - Country:US
Practice Address - Phone:254-752-9774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208650224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant