Provider Demographics
NPI:1063645422
Name:WALL, WILLIAM REGIS JR (MED)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:REGIS
Last Name:WALL
Suffix:JR
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 N CENTRAL AVE
Mailing Address - Street 2:UNIT 14N
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1732
Mailing Address - Country:US
Mailing Address - Phone:602-243-4866
Mailing Address - Fax:
Practice Address - Street 1:6218 S 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-4211
Practice Address - Country:US
Practice Address - Phone:602-304-3117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling