Provider Demographics
NPI:1235847658
Name:WALL, LEWIS DOUGLAS IV (LPC)
Entity Type:Individual
Prefix:MR
First Name:LEWIS
Middle Name:DOUGLAS
Last Name:WALL
Suffix:IV
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 TIMBER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-6350
Mailing Address - Country:US
Mailing Address - Phone:817-709-6609
Mailing Address - Fax:
Practice Address - Street 1:1221 TIMBER CREEK DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-6350
Practice Address - Country:US
Practice Address - Phone:817-709-6609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX85847101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional