Provider Demographics
NPI:1063754877
Name:DENISE C. WALL, LCSW LLC
Entity type:Organization
Organization Name:DENISE C. WALL, LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHO THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:CECILIA
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:302-376-5259
Mailing Address - Street 1:PO BOX 514
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:DE
Mailing Address - Zip Code:19730-0514
Mailing Address - Country:US
Mailing Address - Phone:302-376-5259
Mailing Address - Fax:302-689-4474
Practice Address - Street 1:610 MAIN ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:DE
Practice Address - Zip Code:19730-2012
Practice Address - Country:US
Practice Address - Phone:302-376-5259
Practice Address - Fax:302-689-4474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00003041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1041C0700XOtherTAXONOMY
DE1000032277Medicaid
DE1093814972OtherNPI TYPE I
DE1093814972OtherNPI TYPE I
DE491791Medicare PIN