Provider Demographics
NPI:1538661665
Name:WALL, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 175
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73522-0175
Mailing Address - Country:US
Mailing Address - Phone:580-482-2809
Mailing Address - Fax:580-482-2820
Practice Address - Street 1:111 SEQUOYAH LN
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-1756
Practice Address - Country:US
Practice Address - Phone:580-482-2809
Practice Address - Fax:580-482-2820
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor