Provider Demographics
NPI:1114299146
Name:WALL, PAMELA (LCSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2820
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCISVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70775-2820
Mailing Address - Country:US
Mailing Address - Phone:225-635-5299
Mailing Address - Fax:225-635-3387
Practice Address - Street 1:9794 BAINS ROAD
Practice Address - Street 2:
Practice Address - City:SAINT FRANCISVILLE
Practice Address - State:LA
Practice Address - Zip Code:70775
Practice Address - Country:US
Practice Address - Phone:225-635-5299
Practice Address - Fax:225-635-3387
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical