MEDICARE: MRS. DEMETRIA S WALLS LMSW

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	104100000X	Social Worker	M8329	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902477920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEMETRIA S WALLS LMSW

Provider Business Mailing Address
First Line	:	PO BOX 2305
Second Line	:
City	:	CLINTON
State	:	MS
Zip	:	39060-2305
Country	:	US
Telephone Number	:	601-927-0188
Fax Number	:

Provider Business Practice Location Address
First Line	:	5345 HIGHWAY 18 W
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39209-9421
Country	:	US
Telephone Number	:	601-927-0188
Fax Number	:	601-292-7998

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

Provider Enumeration Date	:	07/09/2021
Last Update Date	:	05/08/2023

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