Provider Demographics
NPI:1073973905
Name:MICHELLE L WALL, LLC
Entity Type:Organization
Organization Name:MICHELLE L WALL, LLC
Other - Org Name:ABC CASE MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, LRC
Authorized Official - Phone:225-667-4014
Mailing Address - Street 1:PO BOX 1284
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70727-1284
Mailing Address - Country:US
Mailing Address - Phone:225-667-4014
Mailing Address - Fax:225-667-4014
Practice Address - Street 1:1 LAKESHORE DR
Practice Address - Street 2:SUITE 1620
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70629-0100
Practice Address - Country:US
Practice Address - Phone:337-421-1510
Practice Address - Fax:337-421-1516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA27071251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2191675Medicaid