Individual
MRS. STEHANIE D WALL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1357 WAYSIDE RD, RAEFORD, NC 28376-6513
(910) 565-2139
Mailing address
3204 HIGH PLAINS DR, HOPE MILLS, NC 28348-5726
(910) 674-8605
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
27-0962043
SC
320800000X
Mental Illness Community Based Residential Treatment Facility
Primary
MHL-047-152
NC
347C00000X
Private Vehicle
27-0962043
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1083045306
STATE FUND
SC
05
—
1083045306
—
SC
Enumeration date
12/12/2013
Last updated
01/09/2015
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