Provider Demographics
NPI:1104268952
Name:HALL, CALVIN JR
Entity type:Individual
Prefix:MR
First Name:CALVIN
Middle Name:
Last Name:HALL
Suffix:JR
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 1:3101 RACKLEY DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32305-6737
Mailing Address - Country:US
Mailing Address - Phone:850-524-1556
Mailing Address - Fax:
Practice Address - Street 1:3101 RACKLEY DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32305-6737
Practice Address - Country:US
Practice Address - Phone:850-524-1556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103TA0700X, 172V00000X
103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0032358001Medicaid
FL003235800Medicaid