Provider Demographics
NPI:1053459156
Name:WALLIS, BILLIE SUE (LCSW)
Entity Type:Individual
Prefix:
First Name:BILLIE
Middle Name:SUE
Last Name:WALLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1254
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-1254
Mailing Address - Country:US
Mailing Address - Phone:337-234-5656
Mailing Address - Fax:337-234-5670
Practice Address - Street 1:1001 W PINHOOK RD STE 305 BLDG 3
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2487
Practice Address - Country:US
Practice Address - Phone:337-237-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9283101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health