Provider Demographics
NPI:1720720949
Name:HALL, WILLIS LEE III
Entity Type:Individual
Prefix:
First Name:WILLIS
Middle Name:LEE
Last Name:HALL
Suffix:III
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 1:706 SOUTHERN LIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MD
Mailing Address - Zip Code:21001-1248
Mailing Address - Country:US
Mailing Address - Phone:443-510-2361
Mailing Address - Fax:
Practice Address - Street 1:1807 E PRESTON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-3131
Practice Address - Country:US
Practice Address - Phone:410-276-2123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD195011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical