Provider Demographics
NPI:1154441137
Name:WALL, JOHN P (MSOTR'L)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:WALL
Suffix:
Gender:M
Credentials:MSOTR'L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BON AIRE TER
Mailing Address - Street 2:
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-3202
Mailing Address - Country:US
Mailing Address - Phone:570-983-9173
Mailing Address - Fax:570-655-4706
Practice Address - Street 1:2 BON AIRE TER
Practice Address - Street 2:
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640-3202
Practice Address - Country:US
Practice Address - Phone:570-983-9173
Practice Address - Fax:570-655-4706
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC006873L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist