MEDICARE: DR. JEDEDIAH WALLS LMHC, ATR-P

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	101YM0800X	Mental Health Counselor	CTB-2022-0028	NM

General Provider Information

NPI Number	:	1174272397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEDEDIAH WALLS LMHC, ATR-P

Provider Business Mailing Address
First Line	:	1304 GREENWOOD LN
Second Line	:
City	:	ALAMOGORDO
State	:	NM
Zip	:	88310-5742
Country	:	US
Telephone Number	:	574-310-3789
Fax Number	:

Provider Business Practice Location Address
First Line	:	133 WYATT DR STE 3
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-2962
Country	:	US
Telephone Number	:	575-526-9878
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2022
Last Update Date	:	03/23/2022

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