Provider Demographics
NPI:1114556081
Name:WALLEN, ERIC LEE NELSON (LMSW)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:LEE NELSON
Last Name:WALLEN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 JANEY DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-9209
Mailing Address - Country:US
Mailing Address - Phone:573-760-5520
Mailing Address - Fax:
Practice Address - Street 1:11 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-1772
Practice Address - Country:US
Practice Address - Phone:573-723-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020009792104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker