Provider Demographics
NPI:1154477404
Name:WALLINGTON, MICHAEL WAYNE (LPCC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:WALLINGTON
Suffix:
Gender:M
Credentials:LPCC
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 KK
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-1570
Mailing Address - Country:US
Mailing Address - Phone:505-751-7037
Mailing Address - Fax:505-751-3010
Practice Address - Street 1:904 E FAIRVIEW LN # B
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2822
Practice Address - Country:US
Practice Address - Phone:505-747-1991
Practice Address - Fax:505-753-6462
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2331101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health