MEDICARE: MR. JOSEPH THEODORE HALE IV LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	817	NC

General Provider Information

NPI Number	:	1487849071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSEPH THEODORE HALE IV LPC

Provider Business Mailing Address
First Line	:	2150 COUNTRY CLUB RD
Second Line	:	210
City	:	WINSTON SALEM
State	:	NC
Zip	:	27104-4241
Country	:	US
Telephone Number	:	336-499-1244
Fax Number	:

Provider Business Practice Location Address
First Line	:	4010 IVY BLUFF TRL
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-2584
Country	:	US
Telephone Number	:	336-922-6349
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2007
Last Update Date	:	09/07/2007

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