Healthcare Provider Details

I. General information

NPI: 1205825544
Provider Name (Legal Business Name): JOHN WESLEY HALL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2157 MCCLINTOCK RD
CHARLOTTE NC
28205-5141
US

IV. Provider business mailing address

2129 E 7TH ST
CHARLOTTE NC
28204-3337
US

V. Phone/Fax

Practice location:
  • Phone: 704-258-5553
  • Fax: 704-344-0078
Mailing address:
  • Phone: 704-258-5553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number2457
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2457
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: