MEDICARE: MICHELLE L WALL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency	27071	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073973905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHELLE L WALL, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1284
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70727-1284
Country	:	US
Telephone Number	:	225-667-4014
Fax Number	:	225-667-4014

Provider Business Practice Location Address
First Line	:	1 LAKESHORE DR
Second Line	:	SUITE 1620
City	:	LAKE CHARLES
State	:	LA
Zip	:	70629-0100
Country	:	US
Telephone Number	:	337-421-1510
Fax Number	:	337-421-1516

Authorized Official
Title or Position	:	OWNER
Name	:	MICHELLE WALL
Credential	:	MHS, LRC
Telephone Number	:	225-667-4014

Provider Enumeration Date	:	03/04/2016
Last Update Date	:	03/04/2016

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Directions to “MICHELLE L WALL, LLC ” Practice Location

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