Provider Demographics
NPI:1700260536
Name:WALLS, DONNA (RN QMHP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:WALLS
Suffix:
Gender:F
Credentials:RN QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-2019
Mailing Address - Country:US
Mailing Address - Phone:815-973-2404
Mailing Address - Fax:
Practice Address - Street 1:208 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-2019
Practice Address - Country:US
Practice Address - Phone:815-973-2404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.310106101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health