Provider Demographics
NPI:1457878365
Name:WALL, BRANDON EARL (LMFT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:EARL
Last Name:WALL
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 39TH ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-6145
Mailing Address - Country:US
Mailing Address - Phone:402-650-6865
Mailing Address - Fax:
Practice Address - Street 1:5300 N PARK PL NE STE 115
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-6220
Practice Address - Country:US
Practice Address - Phone:319-320-7506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA075160106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist