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General NPI Number Information
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NPI Number | 1639408214
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Entity Type | Individual
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Provider Name | DEREK JUSTIN WALL M.S., LPC, NCC
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Gender | Male
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Dates
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Enumeration Date | 12/10/2009
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Last Update Date | 12/10/2009
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Provider Practice Location Address
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Address Line | 12400 OLIVE BLVD SUITE 205
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City | SAINT LOUIS
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State | MO
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Zip | 63141-5454
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Country | US
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Telephone | 314-607-2801
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Fax |
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Provider Business Mailing Address
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Address Line | 13211 WINDYGATE LN
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City | SAINT LOUIS
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State | MO
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Zip | 63146-2227
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Country | US
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Telephone | 314-607-2801
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Fax |
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 2009035484
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180.007223
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License Number State | IL
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