Provider Demographics
NPI:1124058375
Name:WALL, LORI L (PHD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:L
Last Name:WALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 S 14TH ST STE 3
Mailing Address - Street 2:
Mailing Address - City:SEWARD
Mailing Address - State:NE
Mailing Address - Zip Code:68434-2320
Mailing Address - Country:US
Mailing Address - Phone:402-435-3353
Mailing Address - Fax:402-643-2315
Practice Address - Street 1:319 S 14TH ST STE 3
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:NE
Practice Address - Zip Code:68434
Practice Address - Country:US
Practice Address - Phone:402-435-3353
Practice Address - Fax:402-643-2315
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2018-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE460103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-083295526Medicaid
NE47-083295526Medicaid