Provider Demographics
NPI:1053782086
Name:WALL, LAURA (LMHC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 PALOUSE PL
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-9618
Mailing Address - Country:US
Mailing Address - Phone:425-829-0177
Mailing Address - Fax:
Practice Address - Street 1:890 PALOUSE PL
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257-9618
Practice Address - Country:US
Practice Address - Phone:425-829-0177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-16
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC.60379285101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health