Healthcare Provider Details

I. General information

NPI: 1033480660
Provider Name (Legal Business Name): VANESSA R WALLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 W 11TH AVE STE A
EUGENE OR
97402-3780
US

IV. Provider business mailing address

1790 W 11TH AVE STE A
EUGENE OR
97402-3780
US

V. Phone/Fax

Practice location:
  • Phone: 541-868-0661
  • Fax:
Mailing address:
  • Phone: 541-868-0661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: