Healthcare Provider Details

I. General information

NPI: 1659345163
Provider Name (Legal Business Name): RANDOLPH CAREY WALL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 S SHARON AMITY RD
CHARLOTTE NC
28211-2875
US

IV. Provider business mailing address

417 S SHARON AMITY RD
CHARLOTTE NC
28211-2875
US

V. Phone/Fax

Practice location:
  • Phone: 704-364-0452
  • Fax: 704-364-5481
Mailing address:
  • Phone: 704-364-0452
  • Fax: 704-364-5481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1074
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: