Basic Information
| Provider Information | |||||||||
| NPI: | 1568601193 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LMSW, MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 UNION SQ W | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100033304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126279600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 19 UNION SQ W | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100033304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126279600 | ||||||||
| FaxNumber: | 2126274040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2009 | ||||||||
| LastUpdateDate: | 12/08/2010 | ||||||||
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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 | 104100000X | 103 | CO | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 082510 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.