Provider Demographics
NPI:1851545396
Name:WALLIS, JOHN ROBERT (LPC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:WALLIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 S CHUGACH ST
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6795
Mailing Address - Country:US
Mailing Address - Phone:907-746-4080
Mailing Address - Fax:907-746-1177
Practice Address - Street 1:3901 E BOGARD RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6068
Practice Address - Country:US
Practice Address - Phone:907-376-0459
Practice Address - Fax:907-376-0493
Is Sole Proprietor?:No
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA450101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health