Provider Demographics
NPI:1891129052
Name:WALL, MEREDITH (DPT)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:DPT
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 4570
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85261-4570
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1616 N LITCHFIELD RD
Practice Address - Street 2:SUITE 115
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-1252
Practice Address - Country:US
Practice Address - Phone:623-935-0734
Practice Address - Fax:623-935-0934
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016446225100000X
AZ11201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist