Provider Demographics
NPI:1902529415
Name:HALL, KEYONTA SHANNON
Entity Type:Individual
Prefix:MS
First Name:KEYONTA
Middle Name:SHANNON
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 OLD FARM DR
Mailing Address - Street 2:
Mailing Address - City:GREAT MEADOWS
Mailing Address - State:NJ
Mailing Address - Zip Code:07838-6000
Mailing Address - Country:US
Mailing Address - Phone:551-232-6287
Mailing Address - Fax:
Practice Address - Street 1:5700 BOTTINEAU BLVD STE 210
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-3184
Practice Address - Country:US
Practice Address - Phone:763-330-2774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor