Provider Demographics
NPI:1689710782
Name:WALL, NANCY H (OTR)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:H
Last Name:WALL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 WEST ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-2404
Mailing Address - Country:US
Mailing Address - Phone:508-339-9667
Mailing Address - Fax:
Practice Address - Street 1:78 WEST ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048-2404
Practice Address - Country:US
Practice Address - Phone:508-339-9667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4934225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0703541Medicaid
MA0703541Medicaid