Healthcare Provider Details

I. General information

NPI: 1124058375
Provider Name (Legal Business Name): LORI L WALL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 05/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 S 14TH ST STE 3
SEWARD NE
68434
US

IV. Provider business mailing address

319 S 14TH ST STE 3
SEWARD NE
68434-2320
US

V. Phone/Fax

Practice location:
  • Phone: 402-435-3353
  • Fax: 402-643-2315
Mailing address:
  • Phone: 402-435-3353
  • Fax: 402-643-2315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number460
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: