Provider Demographics
NPI:1285702340
Name:WALL, JULIA D (MED, LPC)
Entity type:Individual
Prefix:MRS
First Name:JULIA
Middle Name:D
Last Name:WALL
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 MCCOWAN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-4433
Mailing Address - Country:US
Mailing Address - Phone:936-597-7055
Mailing Address - Fax:936-597-7055
Practice Address - Street 1:208 MCCOWAN ST STE 102
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356-4433
Practice Address - Country:US
Practice Address - Phone:936-597-7055
Practice Address - Fax:936-597-7055
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16065101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096095703Medicaid