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General NPI Number Information
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NPI Number | 1790908374
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Entity Type | Individual
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Provider Name | DEBORAH WALLIS LAC
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Gender | Female
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Dates
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Enumeration Date | 04/11/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1575 HIGHWAY 371 W
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City | NASHVILLE
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State | AR
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Zip | 71852-7598
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Country | US
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Telephone | 870-451-9742
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Fax | 870-451-9752
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Provider Business Mailing Address
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Address Line | 127 WOODRUFF LN
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City | NASHVILLE
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State | AR
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Zip | 71852-7542
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Country | US
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Telephone | 870-557-1094
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | A0302010
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License Number State | AR
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