Provider Demographics
NPI:1801854484
Name:NUNNALLY, WALTER C
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:C
Last Name:NUNNALLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 WASHBURN RD
Mailing Address - Street 2:
Mailing Address - City:WASHBURN
Mailing Address - State:IL
Mailing Address - Zip Code:61570-9384
Mailing Address - Country:US
Mailing Address - Phone:309-444-9900
Mailing Address - Fax:309-444-9901
Practice Address - Street 1:631 N CUMMINGS LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-7501
Practice Address - Country:US
Practice Address - Phone:309-444-9900
Practice Address - Fax:309-444-9901
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2008-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL21633101YA0400X
IL180005889101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)