Provider Demographics
NPI:1134139330
Name:WALL, CYNTHIA JEAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:JEAN
Last Name:WALL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8050 E HIGHWAY 191
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79765-8613
Mailing Address - Country:US
Mailing Address - Phone:432-312-1450
Mailing Address - Fax:432-366-0295
Practice Address - Street 1:8050 E HIGHWAY 191
Practice Address - Street 2:SUITE 206
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79765-8613
Practice Address - Country:US
Practice Address - Phone:432-312-1450
Practice Address - Fax:432-366-0295
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23786103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical