Provider Demographics
NPI:1033426457
Name:WALL, JOHAN (LMFT)
Entity Type:Individual
Prefix:
First Name:JOHAN
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E TULARE AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93292-3629
Mailing Address - Country:US
Mailing Address - Phone:559-623-0908
Mailing Address - Fax:
Practice Address - Street 1:520 E TULARE AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93292-3629
Practice Address - Country:US
Practice Address - Phone:559-623-0908
Practice Address - Fax:559-730-9996
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT48458106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist