Provider Demographics
NPI:1750485371
Name:WALL, DEBRA L (AUD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:L
Last Name:WALL
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 HARCREST DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640
Mailing Address - Country:US
Mailing Address - Phone:989-835-1219
Mailing Address - Fax:989-835-7198
Practice Address - Street 1:1504 HARCREST DR
Practice Address - Street 2:SUITE 3
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4717
Practice Address - Country:US
Practice Address - Phone:989-835-1219
Practice Address - Fax:989-835-7198
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540E610370OtherBCBSM
MI904508130Medicaid
MI0P22880Medicare ID - Type Unspecified