Provider Demographics
NPI:1255782439
Name:WALLIS, ROBERT (LCDC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WALLIS
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8792 COUNTY ROAD 135
Mailing Address - Street 2:
Mailing Address - City:KAUFMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75142-5872
Mailing Address - Country:US
Mailing Address - Phone:214-244-0953
Mailing Address - Fax:
Practice Address - Street 1:8792 COUNTY ROAD 135
Practice Address - Street 2:
Practice Address - City:KAUFMAN
Practice Address - State:TX
Practice Address - Zip Code:75142-5872
Practice Address - Country:US
Practice Address - Phone:214-244-0953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12295101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)