Provider Demographics
NPI:1336538412
Name:WALL, NICOLE (LCMHC)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 NORTH MAIN STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010
Mailing Address - Country:US
Mailing Address - Phone:801-660-5233
Mailing Address - Fax:801-295-4201
Practice Address - Street 1:1355 N MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-5981
Practice Address - Country:US
Practice Address - Phone:801-660-5233
Practice Address - Fax:801-295-4201
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8180027-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health