Provider Demographics
NPI:1073826160
Name:WALL, ALISA RENEE (RRW)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:RENEE
Last Name:WALL
Suffix:
Gender:F
Credentials:RRW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93304-1405
Mailing Address - Country:US
Mailing Address - Phone:661-324-4756
Mailing Address - Fax:661-324-1652
Practice Address - Street 1:1301 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93304-1405
Practice Address - Country:US
Practice Address - Phone:661-324-4756
Practice Address - Fax:661-324-1652
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW197H101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)