Provider Demographics
NPI:1437311727
Name:WALL, NITA M (LMSW)
Entity Type:Individual
Prefix:
First Name:NITA
Middle Name:M
Last Name:WALL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:AR
Mailing Address - Zip Code:72150-2133
Mailing Address - Country:US
Mailing Address - Phone:870-942-5101
Mailing Address - Fax:870-942-7123
Practice Address - Street 1:2500 RIKE DR
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-3937
Practice Address - Country:US
Practice Address - Phone:870-534-1834
Practice Address - Fax:870-534-5798
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2318M101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116378726Medicaid