Provider Demographics
NPI:1639509862
Name:WALLIS, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WALLIS
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 1:10800 EASTWAY
Mailing Address - Street 2:
Mailing Address - City:MCLOUD
Mailing Address - State:OK
Mailing Address - Zip Code:74851-8566
Mailing Address - Country:US
Mailing Address - Phone:580-748-0342
Mailing Address - Fax:405-386-3213
Practice Address - Street 1:201 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-6917
Practice Address - Country:US
Practice Address - Phone:580-748-0342
Practice Address - Fax:405-386-3213
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation