Provider Demographics
NPI:1134281918
Name:WALL, NIKOLA MARIE (LMHC)
Entity Type:Individual
Prefix:
First Name:NIKOLA
Middle Name:MARIE
Last Name:WALL
Suffix:
Gender:F
Credentials:LMHC
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 18
Mailing Address - Street 2:695 SCHOOL STREET
Mailing Address - City:SKANEATELES FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13153-0018
Mailing Address - Country:US
Mailing Address - Phone:315-720-4782
Mailing Address - Fax:315-255-3859
Practice Address - Street 1:1879 W GENESEE STREET RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-9430
Practice Address - Country:US
Practice Address - Phone:315-253-0361
Practice Address - Fax:315-255-3859
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002963101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health