Provider Demographics
NPI:1265617484
Name:WALL, MARK (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 MAPLE SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-8321
Mailing Address - Country:US
Mailing Address - Phone:214-522-1531
Mailing Address - Fax:
Practice Address - Street 1:5030 MAPLE SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-8321
Practice Address - Country:US
Practice Address - Phone:214-522-1531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLPA-4347101Y00000X
TXLPC 01604101YP2500X
TXAPA DIPLOMATE 4720101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor