Provider Demographics
NPI:1881714798
Name:WALLS, THEODORE EDWIN (MA, LMHC, LPC)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:EDWIN
Last Name:WALLS
Suffix:
Gender:M
Credentials:MA, LMHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 STEADY LN
Mailing Address - Street 2:
Mailing Address - City:ASHFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01330-9724
Mailing Address - Country:US
Mailing Address - Phone:413-345-8745
Mailing Address - Fax:
Practice Address - Street 1:54 HARRIS PL STE 105
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6709
Practice Address - Country:US
Practice Address - Phone:802-451-0314
Practice Address - Fax:877-532-0268
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8227101YM0800X
TX16743101YP2500X
VT068.0067951101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140786802Medicaid