Provider Demographics
NPI:1760752125
Name:WALL, ELIZABETH PAMELA (BCBA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:PAMELA
Last Name:WALL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:PAMELA
Other - Last Name:HAWKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:660 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-3101
Mailing Address - Country:US
Mailing Address - Phone:978-339-3256
Mailing Address - Fax:
Practice Address - Street 1:660 PINE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-3101
Practice Address - Country:US
Practice Address - Phone:978-339-3256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist