Provider Demographics
NPI:1568974509
Name:WALL, DANIEL CHRISTOPHER (MA)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:CHRISTOPHER
Last Name:WALL
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3357 PONETA AVE
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-4559
Mailing Address - Country:US
Mailing Address - Phone:386-366-0151
Mailing Address - Fax:
Practice Address - Street 1:911 N SPRING GARDEN AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-2560
Practice Address - Country:US
Practice Address - Phone:386-736-3108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ8136235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist