Provider Demographics
NPI:1053527705
Name:WALL, AMANDA (PSYD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12745 MOORPARK ST
Mailing Address - Street 2:#406
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-1379
Mailing Address - Country:US
Mailing Address - Phone:310-926-1929
Mailing Address - Fax:
Practice Address - Street 1:3255 CAHUENGA BLVD W
Practice Address - Street 2:SUITE 208
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90068-1375
Practice Address - Country:US
Practice Address - Phone:310-926-1929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health