Basic Information
| Provider Information | |||||||||
| NPI: | 1811502206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | LCAS-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420A CORONA ST | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271032817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406021959 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2706 N CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274053657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362729990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2020 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.