Provider Demographics
NPI:1629708094
Name:WALLIS, RETA (LCSW)
Entity Type:Individual
Prefix:
First Name:RETA
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 GOLF COURSE RD STE 1155888
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-7704
Mailing Address - Country:US
Mailing Address - Phone:801-885-4431
Mailing Address - Fax:
Practice Address - Street 1:115 GOLF COURSE RD STE 115
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-7704
Practice Address - Country:US
Practice Address - Phone:801-885-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11730968-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical