Provider Demographics
NPI:1083045306
Name:WALL, STEHANIE D
Entity Type:Individual
Prefix:MRS
First Name:STEHANIE
Middle Name:D
Last Name:WALL
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 1:3204 HIGH PLAINS DR
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-5726
Mailing Address - Country:US
Mailing Address - Phone:910-674-8605
Mailing Address - Fax:
Practice Address - Street 1:1357 WAYSIDE RD
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-6513
Practice Address - Country:US
Practice Address - Phone:910-565-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-047-152320800000X
SC27-0962043171M00000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1083045306Medicaid
SC1083045306OtherSTATE FUND
SC1083045306Medicare NSC