Provider Demographics
NPI:1578383873
Name:WALL, DEBORA LYNN (PTA)
Entity type:Individual
Prefix:
First Name:DEBORA
Middle Name:LYNN
Last Name:WALL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 GREENVALE RD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-4467
Mailing Address - Country:US
Mailing Address - Phone:410-259-6340
Mailing Address - Fax:
Practice Address - Street 1:509 E JOPPA RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-5404
Practice Address - Country:US
Practice Address - Phone:410-828-9494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-12
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA2897208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation