Provider Demographics
NPI:1427116136
Name:HALL, GROVER BENJAMIN (PHD,LCAS, CSI, LPC)
Entity type:Individual
Prefix:DR
First Name:GROVER
Middle Name:BENJAMIN
Last Name:HALL
Suffix:
Gender:M
Credentials:PHD,LCAS, CSI, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11351 INVOLUTE PL APT 103
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-8516
Mailing Address - Country:US
Mailing Address - Phone:919-641-1555
Mailing Address - Fax:919-596-1032
Practice Address - Street 1:11351 INVOLUTE PL APT 103
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-8516
Practice Address - Country:US
Practice Address - Phone:919-641-1555
Practice Address - Fax:919-596-1032
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC161101YA0400X
NC3516101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103113Medicaid