Provider Demographics
NPI:1548802515
Name:WALLS, DUSTIN LEE (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:LEE
Last Name:WALLS
Suffix:
Gender:M
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9414 NE FOURTH PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9414 NE FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6109
Practice Address - Country:US
Practice Address - Phone:360-892-5142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60917848235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty