Provider Demographics
NPI:1346783156
Name:WALL, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 CENTURY DR
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-4530
Mailing Address - Country:US
Mailing Address - Phone:717-480-6785
Mailing Address - Fax:
Practice Address - Street 1:960 CENTURY DR
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-4530
Practice Address - Country:US
Practice Address - Phone:717-480-6785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100777740Medicaid
PA1029202560005Medicaid