Provider Demographics
NPI:1265642631
Name:FALLIS, DEBORAH A (LPC UNDER SUPERVISIO)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:FALLIS
Suffix:
Gender:F
Credentials:LPC UNDER SUPERVISIO
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:A
Other - Last Name:WALSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC UNDER SUPERVISIO
Mailing Address - Street 1:PO BOX 1311
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74821-1311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 CRADDUCK RD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820
Practice Address - Country:US
Practice Address - Phone:580-310-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UNDER SUPERVISION101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health