Provider Demographics
NPI:1194901439
Name:WALL, GLORIA L (PT)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:L
Last Name:WALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4715 PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-3040
Mailing Address - Country:US
Mailing Address - Phone:225-923-0110
Mailing Address - Fax:225-923-0111
Practice Address - Street 1:4715 PERKINS RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-3040
Practice Address - Country:US
Practice Address - Phone:225-923-0110
Practice Address - Fax:225-923-0111
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H610CS23Medicare PIN