Provider Demographics
NPI:1922653567
Name:WALL, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:WALL
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 1:1558 E MILLBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-1530
Mailing Address - Country:US
Mailing Address - Phone:801-510-4142
Mailing Address - Fax:
Practice Address - Street 1:930 W HILL FIELD RD
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4662
Practice Address - Country:US
Practice Address - Phone:801-336-0029
Practice Address - Fax:801-336-3041
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker