1063552586 NPI number — MR. MICHAEL PATRICK WALL LCSWC

Table of content: MR. MICHAEL PATRICK WALL LCSWC (NPI 1063552586)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063552586 NPI number — MR. MICHAEL PATRICK WALL LCSWC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALL
Provider First Name:
MICHAEL
Provider Middle Name:
PATRICK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSWC
Provider Gender Code:
M

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:
1063552586
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
64 DUNGARRIE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTO
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21228-3401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-382-2859
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
692 RITCHIE HWY
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
SEVERNA PARK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21146-3919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-647-4862
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2007

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:  LCSWC07449 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1QV10MP2752664001 . This is a "BCBS MD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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