Provider Demographics
NPI:1649359001
Name:WALL, CYNTHIA LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LYNN
Last Name:WALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30077 SIMPSON LN
Mailing Address - Street 2:PO BOX 2082
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-7759
Mailing Address - Country:US
Mailing Address - Phone:707-964-5229
Mailing Address - Fax:707-964-5766
Practice Address - Street 1:30077 SIMPSON LN
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-7759
Practice Address - Country:US
Practice Address - Phone:707-964-5229
Practice Address - Fax:707-964-5766
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS111931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ00493ZMedicare ID - Type UnspecifiedPSYCHOTHERAPY