Provider Demographics
NPI:1275805053
Name:WALL, DUSTIN A (LPC)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:A
Last Name:WALL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8080 WARD PKWY
Mailing Address - Street 2:SUITE 230
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-2034
Mailing Address - Country:US
Mailing Address - Phone:816-822-1922
Mailing Address - Fax:816-822-2248
Practice Address - Street 1:8080 WARD PKWY
Practice Address - Street 2:SUITE 230
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-2034
Practice Address - Country:US
Practice Address - Phone:816-822-1922
Practice Address - Fax:816-822-2248
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2011008104101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional