Provider Demographics
NPI:1164828794
Name:WALL, HARRIET (LPC)
Entity type:Individual
Prefix:MISS
First Name:HARRIET
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 CANTON ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3615
Mailing Address - Country:US
Mailing Address - Phone:770-993-2676
Mailing Address - Fax:
Practice Address - Street 1:1014 CANTON ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3615
Practice Address - Country:US
Practice Address - Phone:770-993-2676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000853101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor