Healthcare Provider Details

I. General information

NPI: 1619478021
Provider Name (Legal Business Name): NICHOLAS L HALL LCDC II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9620 CAREYS RUN POND CREEK RD
MC DERMOTT OH
45652-3902
US

IV. Provider business mailing address

PO BOX 402
WHEELERSBURG OH
45694-0402
US

V. Phone/Fax

Practice location:
  • Phone: 740-858-6683
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCII.161887
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: