Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist |
NPI | 1063645422 |
---|---|
Provider Name | Mr. William Regis Wall JR. |
First Address | Phoenix, AZ 85012-1732 |
Second Address | Phoenix, AZ 85042-4211 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2009 |
Last Update Date | 01/09/2009 |