Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | CP60700453 | WA |
NPI | 1003449695 |
---|---|
Provider Name | Liam C Wall |
First Address | Walla Walla, WA 99362-8817 |
Second Address | Walla Walla, WA 99362-8817 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/02/2020 |
Last Update Date | 21/02/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2077844 | (05) | WA |