Provider Demographics
NPI:1669522330
Name:WALL, LISA E (LICSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:E
Last Name:WALL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 SQUALICUM PARKWAY
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225
Mailing Address - Country:US
Mailing Address - Phone:360-734-5400
Mailing Address - Fax:360-756-3552
Practice Address - Street 1:2901 SQUALICUM PARKWAY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225
Practice Address - Country:US
Practice Address - Phone:360-734-5400
Practice Address - Fax:360-756-3552
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000079111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAQ20202Medicare UPIN
WAG8805709Medicare PIN