Provider Demographics
NPI:1295272078
Name:WALLIO, STEPHANIE (PHD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WALLIO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 RONDO DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5337
Mailing Address - Country:US
Mailing Address - Phone:785-760-2655
Mailing Address - Fax:
Practice Address - Street 1:1705 RONDO DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5337
Practice Address - Country:US
Practice Address - Phone:785-760-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4722103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical