Provider Demographics
NPI:1831915941
Name:WALL, MIRIAH
Entity type:Individual
Prefix:
First Name:MIRIAH
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1633
Mailing Address - Street 2:
Mailing Address - City:QUECHEE
Mailing Address - State:VT
Mailing Address - Zip Code:05059-0274
Mailing Address - Country:US
Mailing Address - Phone:530-386-2941
Mailing Address - Fax:
Practice Address - Street 1:5 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-7145
Practice Address - Country:US
Practice Address - Phone:530-386-2941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0120317101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health