Provider Demographics
NPI:1437468659
Name:WALL, CHARLAYNE (LCPC)
Entity Type:Individual
Prefix:
First Name:CHARLAYNE
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 W HAVENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-5003
Mailing Address - Country:US
Mailing Address - Phone:208-369-0092
Mailing Address - Fax:
Practice Address - Street 1:1819 W HAVENWOOD AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-5003
Practice Address - Country:US
Practice Address - Phone:208-615-3956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2014-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC5560101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional