Healthcare Provider Details

I. General information

NPI: 1558087999
Provider Name (Legal Business Name): WALL THERAPEUTIC SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 YORKSHIRE ST
SALEM VA
24153-7016
US

IV. Provider business mailing address

405 YORKSHIRE ST
SALEM VA
24153-7016
US

V. Phone/Fax

Practice location:
  • Phone: 540-387-4517
  • Fax: 540-579-0414
Mailing address:
  • Phone: 540-387-4517
  • Fax: 540-579-0414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MATTHEW ROSENBAUM
Title or Position: TREASURER
Credential:
Phone: 540-285-0423