Provider Demographics
NPI:1932740370
Name:WALL, THERESA ANNE (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANNE
Last Name:WALL
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:ANNE
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1007 W AVENUE M14 STE C
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-1443
Mailing Address - Country:US
Mailing Address - Phone:661-947-9554
Mailing Address - Fax:661-947-9337
Practice Address - Street 1:1007 W AVENUE M14 STE C
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-1443
Practice Address - Country:US
Practice Address - Phone:661-947-9554
Practice Address - Fax:661-947-9337
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-19-38473103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst