Provider Demographics
NPI:1619029683
Name:WALL, JUDITH V (LCSW)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:V
Last Name:WALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4104 SE CENTERBOARD LANE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994
Mailing Address - Country:US
Mailing Address - Phone:772-219-0779
Mailing Address - Fax:772-221-7885
Practice Address - Street 1:759 SW FEDERAL HWY
Practice Address - Street 2:#203
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2914
Practice Address - Country:US
Practice Address - Phone:772-219-0779
Practice Address - Fax:772-221-7885
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW30671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL211492500Medicaid
FL088978OtherVALUE OPTIONS
FL112262000OtherMAGELLAN BEHAVIORAL HEALT
Z6535Medicare UPIN
FL211492500Medicaid