Basic Information
| Provider Information | |||||||||
| NPI: | 1538524335 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | SIXTA | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED, LPCA,NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 803 S WALKER ST | ||||||||
| Address2: | |||||||||
| City: | BURGAW | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284255001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103430145 | ||||||||
| FaxNumber: | 9102029966 | ||||||||
| Practice Location | |||||||||
| Address1: | 803 S WALKER ST | ||||||||
| Address2: | |||||||||
| City: | BURGAW | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284255001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102590668 | ||||||||
| FaxNumber: | 9102029966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2015 | ||||||||
| LastUpdateDate: | 10/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 11472 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1538524335 | 05 | NC | MEDICAID |