Provider Demographics
NPI:1366035701
Name:WALA, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:WALA
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 1:4657 N CANFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:NORRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60706-4414
Mailing Address - Country:US
Mailing Address - Phone:773-575-5841
Mailing Address - Fax:
Practice Address - Street 1:5501 S 1100 W
Practice Address - Street 2:
Practice Address - City:WESTVILLE
Practice Address - State:IN
Practice Address - Zip Code:46391-9335
Practice Address - Country:US
Practice Address - Phone:219-785-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043188A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist