Provider Demographics
NPI:1912354978
Name:WALL, MIKEA
Entity Type:Individual
Prefix:
First Name:MIKEA
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 1:711 PENN AVE
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:WILKINSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15221-2216
Mailing Address - Country:US
Mailing Address - Phone:412-241-4673
Mailing Address - Fax:412-241-4675
Practice Address - Street 1:711 PENN AVE
Practice Address - Street 2:FLOOR 2
Practice Address - City:WILKINSBURG
Practice Address - State:PA
Practice Address - Zip Code:15221-2216
Practice Address - Country:US
Practice Address - Phone:412-241-4673
Practice Address - Fax:412-241-4675
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW133132104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker