Healthcare Provider Details

I. General information

NPI: 1346176419
Provider Name (Legal Business Name): BRENNAN WALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 W MINNESOTA PARK RD STE A
HAMMOND LA
70403-6149
US

IV. Provider business mailing address

10377 LONE PINE RD
DENHAM SPRINGS LA
70726-5851
US

V. Phone/Fax

Practice location:
  • Phone: 985-549-1900
  • Fax: 985-549-1888
Mailing address:
  • Phone: 985-792-5996
  • Fax: 985-792-5998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12435
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: