Provider Demographics
NPI:1457679680
Name:WALL, KIMBERLY DAWN (MED)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:WALL
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 MAIN STREET. SUITE 560
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608
Mailing Address - Country:US
Mailing Address - Phone:508-890-6519
Mailing Address - Fax:508-363-0562
Practice Address - Street 1:484 MAIN ST STE 560
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1817
Practice Address - Country:US
Practice Address - Phone:508-890-6519
Practice Address - Fax:508-363-0562
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional