Provider Demographics
NPI:1083167456
Name:WALL, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 OLD PIKE RD
Mailing Address - Street 2:
Mailing Address - City:CORNISH
Mailing Address - State:ME
Mailing Address - Zip Code:04020-3506
Mailing Address - Country:US
Mailing Address - Phone:207-625-4300
Mailing Address - Fax:
Practice Address - Street 1:16 OLD PIKE RD
Practice Address - Street 2:
Practice Address - City:CORNISH
Practice Address - State:ME
Practice Address - Zip Code:04020-3506
Practice Address - Country:US
Practice Address - Phone:207-625-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT4537225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist