Provider Demographics
NPI:1518006709
Name:WALLIS, FABIANA (PHD)
Entity Type:Individual
Prefix:
First Name:FABIANA
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 SE 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1441
Mailing Address - Country:US
Mailing Address - Phone:503-889-2849
Mailing Address - Fax:503-735-0912
Practice Address - Street 1:7 SE 30TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1902
Practice Address - Country:US
Practice Address - Phone:503-939-4737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1657103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical