Provider Demographics
NPI:1982565537
Name:WALL, ANGEL MALANA
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:MALANA
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 LISSON CRES
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4242
Mailing Address - Country:US
Mailing Address - Phone:828-337-8812
Mailing Address - Fax:
Practice Address - Street 1:2920 W BROAD ST STE 215
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-5103
Practice Address - Country:US
Practice Address - Phone:804-988-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-22
Last Update Date:2025-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician