Provider Demographics
NPI:1750795423
Name:WALL, JUDY DENISE (PTA)
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:DENISE
Last Name:WALL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 S CAMILLE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3624
Mailing Address - Country:US
Mailing Address - Phone:954-336-4183
Mailing Address - Fax:
Practice Address - Street 1:4425 S CAMILLE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3624
Practice Address - Country:US
Practice Address - Phone:954-336-4183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8398928-2402174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist