Provider Demographics
NPI:1851920466
Name:WALL, SHEILA N (MT-BC)
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:N
Last Name:WALL
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3740 SPOONER AVE STE C
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-1007
Mailing Address - Country:US
Mailing Address - Phone:715-514-1978
Mailing Address - Fax:
Practice Address - Street 1:3740 SPOONER AVE STE C
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-1097
Practice Address - Country:US
Practice Address - Phone:715-514-1978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
13980225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
13980OtherBOARD CERTIFICATION NUMBER
WI176-38OtherDFI WISCONSIN