Basic Information
| Provider Information | |||||||||
| NPI: | 1033426457 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | JOHAN | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 E TULARE AVE | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932923629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596230908 | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 E TULARE AVE | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932923629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596230908 | ||||||||
| FaxNumber: | 5597309996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2010 | ||||||||
| LastUpdateDate: | 01/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT48458 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.