Healthcare Provider Details

I. General information

NPI: 1619744976
Provider Name (Legal Business Name): CAITLIN R WALLS LPCMH, LAAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E 12TH ST
WILMINGTON DE
19801-3403
US

IV. Provider business mailing address

401 E 12TH ST
WILMINGTON DE
19801-3403
US

V. Phone/Fax

Practice location:
  • Phone: 302-576-8080
  • Fax: 302-576-8084
Mailing address:
  • Phone: 302-576-8080
  • Fax: 302-576-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC-0011332
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberAS-0010001
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: