Basic Information
Provider Information | |||||||||
NPI: | 1972528388 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALL | ||||||||
FirstName: | TAMARA | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3350 LA JOLLA VILLAGE DR. | ||||||||
Address2: | VA SAN DIEGO HEALTHCARE SYSTEM | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 92161 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585528585 | ||||||||
FaxNumber: | 8585527414 | ||||||||
Practice Location | |||||||||
Address1: | VA SAN DIEGO HEALTHCARE SYSTEM | ||||||||
Address2: | 3350 LA JOLLA VILLAGE DR. | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921610001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585528585 | ||||||||
FaxNumber: | 8585527414 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X | PSY15385 | CA | X |   | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 103TA0700X | PSY15385 | CA | X |   | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | 103TB0200X | PSY15385 | CA | X |   | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | PSY15385 | CA | X |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | PSY15385 | CA | X |   | Behavioral Health & Social Service Providers | Psychologist |   | 103TP2701X | PSY15385 | CA | X |   | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
No ID Information.