Healthcare Provider Details

I. General information

NPI: 1568787026
Provider Name (Legal Business Name): EMMA WALL BMBCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2010
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 UCLA MEDICAL PLZ ROOM 1524 - DIVISION OF CHILD PSYCHIATRY
LOS ANGELES CA
90095-6968
US

IV. Provider business mailing address

300 UCLA MEDICAL PLZ ROOM 1524 - DIVISION OF CHILD PSYCHIATRY
LOS ANGELES CA
90095-6968
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-7773
  • Fax:
Mailing address:
  • Phone: 310-825-7733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA137109
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA137109
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: