Healthcare Provider Details

I. General information

NPI: 1619029683
Provider Name (Legal Business Name): JUDITH V WALL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

759 SW FEDERAL HWY #203
STUART FL
34994-2914
US

IV. Provider business mailing address

4104 SE CENTERBOARD LANE SUITE 205
STUART FL
34994
US

V. Phone/Fax

Practice location:
  • Phone: 772-219-0779
  • Fax: 772-221-7885
Mailing address:
  • Phone: 772-219-0779
  • Fax: 772-221-7885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW3067
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: