Provider Demographics
NPI:1821631532
Name:WALLS, MARQUITA LATRICE
Entity Type:Individual
Prefix:
First Name:MARQUITA
Middle Name:LATRICE
Last Name:WALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 YELLOWSTONE CT APT B
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-1770
Mailing Address - Country:US
Mailing Address - Phone:704-915-0282
Mailing Address - Fax:
Practice Address - Street 1:1565 LONGBRANCH RD
Practice Address - Street 2:
Practice Address - City:GROVER
Practice Address - State:NC
Practice Address - Zip Code:28073-9599
Practice Address - Country:US
Practice Address - Phone:704-915-0282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children