Provider Demographics
NPI:1154510915
Name:WALLS, LISA NICOLE (MED)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:NICOLE
Last Name:WALLS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:NICOLE
Other - Last Name:WALLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED
Mailing Address - Street 1:9239 SCARLETT DR SW
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2086
Mailing Address - Country:US
Mailing Address - Phone:678-389-0755
Mailing Address - Fax:
Practice Address - Street 1:175 GWINNETT DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-8444
Practice Address - Country:US
Practice Address - Phone:770-339-5377
Practice Address - Fax:770-339-5016
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)