Provider Demographics
NPI:1982953519
Name:WALLIS, THERESE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:THERESE
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 M 139
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-5711
Mailing Address - Country:US
Mailing Address - Phone:269-925-0585
Mailing Address - Fax:269-927-1326
Practice Address - Street 1:115 S SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2848
Practice Address - Country:US
Practice Address - Phone:269-684-4270
Practice Address - Fax:269-684-4070
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010605651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical