Provider Demographics
NPI:1851832158
Name:WALLS, ERIC DANIEL (MA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:DANIEL
Last Name:WALLS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 3RD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1344
Mailing Address - Country:US
Mailing Address - Phone:304-744-8866
Mailing Address - Fax:
Practice Address - Street 1:515 3RD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1344
Practice Address - Country:US
Practice Address - Phone:304-744-8866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1113103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical