Provider Demographics
NPI:1760862460
Name:WALLS, RONINA (MED)
Entity Type:Individual
Prefix:
First Name:RONINA
Middle Name:
Last Name:WALLS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 NW CENTRAL AVENUE
Mailing Address - Street 2:N
Mailing Address - City:AMITE
Mailing Address - State:LA
Mailing Address - Zip Code:70422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 NW CENTRAL AVENUE
Practice Address - Street 2:N
Practice Address - City:AMITE
Practice Address - State:LA
Practice Address - Zip Code:70422
Practice Address - Country:US
Practice Address - Phone:985-474-5455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5940101YM0800X, 101YP2500X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator