Provider Demographics
NPI:1013162072
Name:WALL, TERRY L (MA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:WALL
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 1:1100 US HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:BANNER
Mailing Address - State:WY
Mailing Address - Zip Code:82832-9711
Mailing Address - Country:US
Mailing Address - Phone:307-751-1406
Mailing Address - Fax:
Practice Address - Street 1:45 E LOUCKS ST
Practice Address - Street 2:SUITE 301
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6339
Practice Address - Country:US
Practice Address - Phone:307-751-1406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLMFT-078106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist