Provider Demographics
NPI:1336698125
Name:NALLS, ALONZO E
Entity Type:Individual
Prefix:
First Name:ALONZO
Middle Name:E
Last Name:NALLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-585-8170
Mailing Address - Fax:541-858-8167
Practice Address - Street 1:210 COVE RD
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415
Practice Address - Country:US
Practice Address - Phone:541-469-0222
Practice Address - Fax:541-469-0228
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health