Provider Demographics
NPI:1053101899
Name:HALL, SHANNON LEA (BA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEA
Last Name:HALL
Suffix:
Gender:
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 LONDON LN
Mailing Address - Street 2:
Mailing Address - City:HEALDTON
Mailing Address - State:OK
Mailing Address - Zip Code:73438-3247
Mailing Address - Country:US
Mailing Address - Phone:580-768-3240
Mailing Address - Fax:
Practice Address - Street 1:1004 REPUBLIC ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-4555
Practice Address - Country:US
Practice Address - Phone:580-768-3240
Practice Address - Fax:580-768-3240
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility