Provider Demographics
NPI:1205415924
Name:HALLMON, DERRECO
Entity type:Individual
Prefix:
First Name:DERRECO
Middle Name:
Last Name:HALLMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 W PEACHTREE ST NW APT 1202
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-4735
Mailing Address - Country:US
Mailing Address - Phone:404-579-2390
Mailing Address - Fax:
Practice Address - Street 1:1240 W PEACHTREE ST NW APT 1202
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-4735
Practice Address - Country:US
Practice Address - Phone:404-579-2390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health