Provider Demographics
NPI:1518636042
Name:WALLIS, LAUREN ELIZABETH (MA, LLPC)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:WALLIS
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3274 SANDCREST ST SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1477
Mailing Address - Country:US
Mailing Address - Phone:616-304-2599
Mailing Address - Fax:
Practice Address - Street 1:92 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SARANAC
Practice Address - State:MI
Practice Address - Zip Code:48881-5102
Practice Address - Country:US
Practice Address - Phone:616-642-6466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451019727101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health