Provider Demographics
NPI:1720231160
Name:WALL, STEVEN R
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:R
Last Name:WALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 ARCHER CT
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-6432
Mailing Address - Country:US
Mailing Address - Phone:321-720-2049
Mailing Address - Fax:
Practice Address - Street 1:218 PARNELL ST
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4714
Practice Address - Country:US
Practice Address - Phone:321-720-2049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA54448225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist