Provider Demographics
NPI:1972078657
Name:WALLS, BRYANT WILLIS (LICSW)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:WILLIS
Last Name:WALLS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MERRIAM WAY
Mailing Address - Street 2:
Mailing Address - City:UPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01568-1675
Mailing Address - Country:US
Mailing Address - Phone:508-647-6400
Mailing Address - Fax:
Practice Address - Street 1:22 RUTLEDGE RD
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-1729
Practice Address - Country:US
Practice Address - Phone:508-647-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA114169-SW-LICSW1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool