Provider Demographics
NPI:1174004634
Name:WALLIS, DONNA JO EMILY
Entity Type:Individual
Prefix:MRS
First Name:DONNA JO
Middle Name:EMILY
Last Name:WALLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8961 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48623-8717
Mailing Address - Country:US
Mailing Address - Phone:989-259-9984
Mailing Address - Fax:
Practice Address - Street 1:203 S WASHINGTON AVE STE 30
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48607-1217
Practice Address - Country:US
Practice Address - Phone:989-259-9984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2023-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103K00000X
106S00000X
MI7401001383103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician