Provider Demographics
NPI:1780076877
Name:HALLIBURTON, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:HALLIBURTON
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 1:1122 SAM NEWELL RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1122 SAM NEWELL RD
Practice Address - Street 2:SUITE 112
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5015
Practice Address - Country:US
Practice Address - Phone:980-292-3586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA11374101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty