MEDICARE: MR. RANDY LEE WALL LPC, NCC

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	101YP1600X	Pastoral Counselor	5048	NC

General Provider Information

NPI Number	:	1700919099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDY LEE WALL LPC, NCC

Provider Business Mailing Address
First Line	:	2560 COLD SPRINGS RD E
Second Line	:
City	:	CONCORD
State	:	NC
Zip	:	28025-8004
Country	:	US
Telephone Number	:	704-789-3975
Fax Number	:

Provider Business Practice Location Address
First Line	:	2560 COLD SPRINGS RD E
Second Line	:
City	:	CONCORD
State	:	NC
Zip	:	28025-8004
Country	:	US
Telephone Number	:	704-789-3975
Fax Number	:

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

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	07/08/2007

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