Provider Demographics
NPI:1265807325
Name:HALL, GLENZETTA
Entity type:Individual
Prefix:
First Name:GLENZETTA
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 29372
Mailing Address - Street 2:
Mailing Address - City:SH
Mailing Address - State:LA
Mailing Address - Zip Code:71149
Mailing Address - Country:US
Mailing Address - Phone:318-670-8898
Mailing Address - Fax:318-300-3772
Practice Address - Street 1:7611 SAINT VINCENT AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-4231
Practice Address - Country:US
Practice Address - Phone:318-868-4552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6405101YP2500X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional