Provider Demographics
NPI:1295921385
Name:WALLIS, KATHRYN DIANE (MS/CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:DIANE
Last Name:WALLIS
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 GREYSOLON RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55812-2306
Mailing Address - Country:US
Mailing Address - Phone:218-349-0589
Mailing Address - Fax:
Practice Address - Street 1:2610 GREYSOLON RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-2306
Practice Address - Country:US
Practice Address - Phone:218-349-0589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2010-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5644235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist