Provider Demographics
NPI:1568192565
Name:WALL, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 GLENBROOK RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037-2013
Mailing Address - Country:US
Mailing Address - Phone:203-200-8075
Mailing Address - Fax:
Practice Address - Street 1:270 FARMINGTON AVE STE 365
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1926
Practice Address - Country:US
Practice Address - Phone:860-255-4738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT122261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical