Provider Demographics
NPI:1972528388
Name:WALL, TAMARA LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:LYNN
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 1:3350 LA JOLLA VILLAGE DR.
Mailing Address - Street 2:VA SAN DIEGO HEALTHCARE SYSTEM
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92161
Mailing Address - Country:US
Mailing Address - Phone:858-552-8585
Mailing Address - Fax:858-552-7414
Practice Address - Street 1:VA SAN DIEGO HEALTHCARE SYSTEM
Practice Address - Street 2:3350 LA JOLLA VILLAGE DR.
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0001
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:858-552-7414
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15385103TA0400X, 103TA0700X, 103TB0200X, 103TC0700X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy