Provider Demographics
NPI:1114228384
Name:DE WALL, ROBERT ANDREW (LCPC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ANDREW
Last Name:DE WALL
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 FORDHAM ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3418
Mailing Address - Country:US
Mailing Address - Phone:208-317-0027
Mailing Address - Fax:208-234-2800
Practice Address - Street 1:444 HOSPITAL WAY STE 477
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2744
Practice Address - Country:US
Practice Address - Phone:208-233-7832
Practice Address - Fax:208-233-7835
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-4672101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional