Provider Demographics
NPI:1841609138
Name:WALLS, MELISSA (MA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WALLS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5739 BYRON ANTHONY PL STE 1001
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-8638
Mailing Address - Country:US
Mailing Address - Phone:321-483-7880
Mailing Address - Fax:
Practice Address - Street 1:5739 BYRON ANTHONY PL STE 1001
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-8638
Practice Address - Country:US
Practice Address - Phone:321-483-7880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL1-18-34001103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst