Provider Demographics
NPI:1497819973
Name:WALL PSYCHOLOGY A PSYCHOLOGICAL CORPORATION
Entity Type:Organization
Organization Name:WALL PSYCHOLOGY A PSYCHOLOGICAL CORPORATION
Other - Org Name:PSYCHSANDIEGO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALESSANDRA
Authorized Official - Middle Name:SONBOLEH ANTONIA
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:858-352-8027
Mailing Address - Street 1:311 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1630
Mailing Address - Country:US
Mailing Address - Phone:858-352-8027
Mailing Address - Fax:619-231-1050
Practice Address - Street 1:311 LAUREL ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1630
Practice Address - Country:US
Practice Address - Phone:858-352-8027
Practice Address - Fax:619-231-1050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20775103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY20775OtherLICENSE NUMBER