Provider Demographics
NPI:1851373245
Name:WALL, WILLIAM GRAHAM (LICSW, BCD)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:GRAHAM
Last Name:WALL
Suffix:
Gender:M
Credentials:LICSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3094 GLENSHAW DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-5827
Mailing Address - Country:US
Mailing Address - Phone:937-257-6877
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:WRIGHT PATTERSON MEDICAL CENTER
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5546
Practice Address - Country:US
Practice Address - Phone:937-257-6876
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3508-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical