Provider Demographics
NPI:1467234641
Name:HALL, TRIPP LANE
Entity type:Individual
Prefix:MR
First Name:TRIPP
Middle Name:LANE
Last Name:HALL
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 1:702 W WOOD ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-4705
Mailing Address - Country:US
Mailing Address - Phone:405-585-3777
Mailing Address - Fax:
Practice Address - Street 1:602 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:OK
Practice Address - Zip Code:74873-2020
Practice Address - Country:US
Practice Address - Phone:405-585-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11811101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional