Provider Demographics
NPI:1255768842
Name:WALLS, IZELLA
Entity type:Individual
Prefix:
First Name:IZELLA
Middle Name:
Last Name:WALLS
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 1:4425 JAMIE CT
Mailing Address - Street 2:#208
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3138
Mailing Address - Country:US
Mailing Address - Phone:175-423-9876
Mailing Address - Fax:
Practice Address - Street 1:4425 JAMIE CT
Practice Address - Street 2:208
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3138
Practice Address - Country:US
Practice Address - Phone:754-423-9876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health