MEDICARE: MICHAEL WAYNE WALLINGTON LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	2331	NM

General Provider Information

NPI Number	:	1154477404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL WAYNE WALLINGTON LPCC

Provider Business Mailing Address
First Line	:	PO BOX KK
Second Line	:
City	:	TAOS
State	:	NM
Zip	:	87571-1570
Country	:	US
Telephone Number	:	505-751-7037
Fax Number	:	505-751-3010

Provider Business Practice Location Address
First Line	:	904 E FAIRVIEW LN # B
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2822
Country	:	US
Telephone Number	:	505-747-1991
Fax Number	:	505-753-6462

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	07/08/2007

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