Provider Demographics
NPI:1730424623
Name:WALL, MICHELLE (OTR/L)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 VIVIAN AVE
Mailing Address - Street 2:
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1000
Mailing Address - Country:US
Mailing Address - Phone:201-906-6364
Mailing Address - Fax:
Practice Address - Street 1:296 HAMBURG TPKE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2150
Practice Address - Country:US
Practice Address - Phone:973-790-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist