Provider Demographics
NPI:1629384318
Name:WALLIS, AMIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6141
Mailing Address - Country:US
Mailing Address - Phone:501-329-5459
Mailing Address - Fax:501-327-1738
Practice Address - Street 1:2740 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6141
Practice Address - Country:US
Practice Address - Phone:501-329-5459
Practice Address - Fax:501-327-1738
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#3072235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist