Provider Demographics
NPI:1861097164
Name:WALL, MARY M (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:WALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MISSY
Other - Middle Name:M
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:2202 LONGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-5316
Mailing Address - Country:US
Mailing Address - Phone:214-797-8303
Mailing Address - Fax:
Practice Address - Street 1:2202 LONGWOOD LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-5316
Practice Address - Country:US
Practice Address - Phone:214-797-8303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX564141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical