Provider Demographics
NPI:1588029326
Name:WALLS, ANGELA LEA (MA)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:LEA
Last Name:WALLS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-3867
Mailing Address - Country:US
Mailing Address - Phone:765-662-9971
Mailing Address - Fax:
Practice Address - Street 1:101 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-3867
Practice Address - Country:US
Practice Address - Phone:765-662-9971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100124250Medicaid