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General NPI Number Information
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NPI Number | 1275719718
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Entity Type | Individual
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Provider Name | TERRI NORTHUP WALL PH.D.
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Gender | Female
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Dates
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Enumeration Date | 01/15/2008
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Last Update Date | 01/15/2008
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Provider Practice Location Address
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Address Line | 13500 SUTTON PARK DR S SUITE 203
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City | JACKSONVILLE
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State | FL
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Zip | 32224-5251
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Country | US
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Telephone | 904-992-9930
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Fax | 904-992-9937
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Provider Business Mailing Address
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Address Line | 13500 SUTTON PARK DR S SUITE 203
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City | JACKSONVILLE
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State | FL
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Zip | 32224-5251
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Country | US
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Telephone | 904-992-9930
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Fax | 904-992-9937
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY 6112
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License Number State | FL
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