Healthcare Provider Details

I. General information

NPI: 1093206831
Provider Name (Legal Business Name): KEITH WALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7933 E 49TH PL
DENVER CO
80238-3266
US

IV. Provider business mailing address

7933 E 49TH PL
DENVER CO
80238-3266
US

V. Phone/Fax

Practice location:
  • Phone: 720-299-9302
  • Fax:
Mailing address:
  • Phone: 720-299-9302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC.0019912
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: