Healthcare Provider Details

I. General information

NPI: 1891129052
Provider Name (Legal Business Name): MEREDITH WALL DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2013
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 N LITCHFIELD RD SUITE 115
GOODYEAR AZ
85395-1252
US

IV. Provider business mailing address

PO BOX 4570
SCOTTSDALE AZ
85261-4570
US

V. Phone/Fax

Practice location:
  • Phone: 623-935-0734
  • Fax: 623-935-0934
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501016446
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11201
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: