Healthcare Provider Details

I. General information

NPI: 1922425776
Provider Name (Legal Business Name): CHRISTA ANN WALLIS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2014
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1881 BUSINESS CENTER DR
SAN BERNARDINO CA
92408-3465
US

IV. Provider business mailing address

PO BOX 10427
SAN BERNARDINO CA
92423-0427
US

V. Phone/Fax

Practice location:
  • Phone: 909-884-0133
  • Fax: 909-384-0734
Mailing address:
  • Phone: 909-884-0133
  • Fax: 909-384-0734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number48068
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: