Provider Demographics
NPI:1275997769
Name:WALLIS, DOROTHY (LMSW)
Entity Type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1949
Mailing Address - Country:US
Mailing Address - Phone:615-251-8805
Mailing Address - Fax:
Practice Address - Street 1:402 22ND AVE N
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1949
Practice Address - Country:US
Practice Address - Phone:615-251-8805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43-2001774104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH445756Medicaid