Provider Demographics
NPI:1447866413
Name:WALL, ANTANAYA I
Entity type:Individual
Prefix:
First Name:ANTANAYA
Middle Name:I
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 1:614 COOPER HILL RD
Mailing Address - Street 2:
Mailing Address - City:WYNANTSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12198-2906
Mailing Address - Country:US
Mailing Address - Phone:518-283-6500
Mailing Address - Fax:
Practice Address - Street 1:614 COOPER HILL RD
Practice Address - Street 2:
Practice Address - City:WYNANTSKILL
Practice Address - State:NY
Practice Address - Zip Code:12198-2906
Practice Address - Country:US
Practice Address - Phone:518-283-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1041C0700X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical