Provider Demographics
NPI:1821768342
Name:WALL, CARLA A (PHD LCP)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:A
Last Name:WALL
Suffix:
Gender:F
Credentials:PHD LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 780125
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0125
Mailing Address - Country:US
Mailing Address - Phone:804-922-4844
Mailing Address - Fax:
Practice Address - Street 1:2924 BROOK RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-1215
Practice Address - Country:US
Practice Address - Phone:804-828-2467
Practice Address - Fax:804-628-1236
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810008301103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical