Provider Demographics
NPI:1780826636
Name:WALL, MARY ELIZABETH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA-CCC/SLP
Mailing Address - Street 1:PO BOX 2290
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557-2290
Mailing Address - Country:US
Mailing Address - Phone:575-758-5763
Mailing Address - Fax:
Practice Address - Street 1:7 COYOTE COURT
Practice Address - Street 2:BOX 2290 RDT, NM 87557
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-758-5763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1057235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist