Lisa Marie Wall

Key facts

NPI

1104245513

Entity type

Individual (NPI type 1)

Primary specialty

Behavior Analyst 103K00000X

License

1-14-15120 (NJ)

Practice address

496 Rena CT
Brick, NJ 08724-7150

Phone

(848) 448-4002

NPI assigned

Apr 14, 2014

Sex

Female

Sole proprietor

No

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Complete Rehabilitation and Sports Physical Therapy, PC Physical Therapist · Ronkonkoma, NY · NPI 1811097306
  NPD (past)

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

State licenses

Practice roles

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Aug 19, 2025.

{
    "created_epoch": "1397433600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1755561600000",
    "number": "1104245513",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "496 RENA CT",
            "city": "BRICK",
            "state": "NJ",
            "postal_code": "087247150"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "496 RENA CT",
            "city": "BRICK",
            "state": "NJ",
            "postal_code": "087247150",
            "telephone_number": "848-448-4002"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "300 Market St Ste 200",
            "address_purpose": "LOCATION",
            "city": "Chapel Hill",
            "state": "NC",
            "postal_code": "275164493",
            "country_code": "US",
            "telephone_number": "984-528-8787",
            "fax_number": "984-246-1223",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALL",
        "first_name": "LISA",
        "middle_name": "MARIE",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2014-04-14",
        "last_updated": "2025-08-19",
        "certification_date": "2025-08-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": "NC",
            "license": null,
            "primary": false
        },
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": "NC",
            "license": "3245",
            "primary": false
        },
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": "NJ",
            "license": "1-14-15120",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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All providers in Brick, NJ · Behavior Analyst in New Jersey