Provider Demographics
NPI:1629583307
Name:WALLEN, LORRETA AKINYI
Entity Type:Individual
Prefix:MRS
First Name:LORRETA
Middle Name:AKINYI
Last Name:WALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12433 ADMIRALTY WAY APT K302
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-7559
Mailing Address - Country:US
Mailing Address - Phone:817-312-4558
Mailing Address - Fax:
Practice Address - Street 1:12433 ADMIRALTY WAY APT K302
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-7559
Practice Address - Country:US
Practice Address - Phone:817-312-4558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty