Provider Demographics
NPI:1578272795
Name:WALLS, KATHLEEN (LCMHC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WALLS
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1188 THREE MILE BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-9136
Mailing Address - Country:US
Mailing Address - Phone:802-989-8363
Mailing Address - Fax:
Practice Address - Street 1:1188 THREE MILE BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-9136
Practice Address - Country:US
Practice Address - Phone:802-989-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0134984101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health