Provider Demographics
NPI:1740357813
Name:WALLIS, SUSAN D (PLMHP, PCMSW, MSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:WALLIS
Suffix:
Gender:F
Credentials:PLMHP, PCMSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5646 OHIO ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-4138
Mailing Address - Country:US
Mailing Address - Phone:408-806-8156
Mailing Address - Fax:
Practice Address - Street 1:2101 S 42ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-2909
Practice Address - Country:US
Practice Address - Phone:402-553-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7196104100000X
NE11317101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker