Provider Demographics
NPI:1093037384
Name:WALLIS, KERRY MICHAEL (LMHC, CAP)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:MICHAEL
Last Name:WALLIS
Suffix:
Gender:M
Credentials:LMHC, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-2803
Mailing Address - Country:US
Mailing Address - Phone:561-210-8300
Mailing Address - Fax:561-210-8301
Practice Address - Street 1:1200 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-2803
Practice Address - Country:US
Practice Address - Phone:561-210-8300
Practice Address - Fax:561-210-8301
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-27
Last Update Date:2010-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 10146101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health