Provider Demographics
NPI:1881997468
Name:WALL, ALYSA GREDEL (PSYD)
Entity type:Individual
Prefix:
First Name:ALYSA
Middle Name:GREDEL
Last Name:WALL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1276 MCCONNELL DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3508
Mailing Address - Country:US
Mailing Address - Phone:404-929-9009
Mailing Address - Fax:404-929-9005
Practice Address - Street 1:1276 MCCONNELL DR
Practice Address - Street 2:SUITE C
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3508
Practice Address - Country:US
Practice Address - Phone:404-929-9009
Practice Address - Fax:404-929-9005
Is Sole Proprietor?:No
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPS-P000213103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist