1053346502 NPI number — REGINA WALL MSW LCSW BCD

Table of content: REGINA WALL MSW LCSW BCD (NPI 1053346502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053346502 NPI number — REGINA WALL MSW LCSW BCD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALL
Provider First Name:
REGINA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW LCSW BCD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053346502
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 POINT CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08648-2861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-434-1418
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 STRAUBE CENTER BLVD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
PENNINGTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08534-1447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-298-9144
Provider Business Practice Location Address Fax Number:
609-298-9288
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SC01436 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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