Provider Demographics
NPI:1104971035
Name:WALL, NANCY CARON (MS LMFT)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:CARON
Last Name:WALL
Suffix:
Gender:F
Credentials:MS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 463
Mailing Address - Street 2:
Mailing Address - City:PLANTSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06479-1323
Mailing Address - Country:US
Mailing Address - Phone:203-699-9996
Mailing Address - Fax:203-271-3575
Practice Address - Street 1:345 HIGHLAND AVE
Practice Address - Street 2:102
Practice Address - City:CHESIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-1246
Practice Address - Country:US
Practice Address - Phone:203-699-9996
Practice Address - Fax:203-271-3575
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000675106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist