Basic Information
| Provider Information | |||||||||
| NPI: | 1669522330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 SQUALICUM PARKWAY | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607345400 | ||||||||
| FaxNumber: | 3607563552 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 SQUALICUM PARKWAY | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607345400 | ||||||||
| FaxNumber: | 3607563552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LW00007911 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.