MEDICARE: DR. MARK WALL PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	LPA-4347	TX
2	101YP2500X	Professional Counselor	LPC 01604	TX
3	101YP2500X	Professional Counselor	APA DIPLOMATE 4720	TX

General Provider Information

NPI Number	:	1265617484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK WALL PHD

Provider Business Mailing Address
First Line	:	5030 MAPLE SPRINGS BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-8321
Country	:	US
Telephone Number	:	214-522-1531
Fax Number	:

Provider Business Practice Location Address
First Line	:	5030 MAPLE SPRINGS BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-8321
Country	:	US
Telephone Number	:	214-522-1531
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2008
Last Update Date	:	01/07/2008

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Directions to “ DR. MARK WALL PHD” Practice Location

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