Healthcare Provider Details

I. General information

NPI: 1164981452
Provider Name (Legal Business Name): JOEL WALLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 E 770 N
OREM UT
84097-4101
US

IV. Provider business mailing address

520 E 770 N
OREM UT
84097-4101
US

V. Phone/Fax

Practice location:
  • Phone: 385-412-9880
  • Fax:
Mailing address:
  • Phone: 385-412-9880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: