MEDICARE: MORGAN WALLIS LAC

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	LAC-23276	AZ

General Provider Information

NPI Number	:	1205285087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MORGAN WALLIS LAC

Provider Business Mailing Address
First Line	:	8507 E KEATS AVE
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85209-4360
Country	:	US
Telephone Number	:	208-447-0803
Fax Number	:

Provider Business Practice Location Address
First Line	:	2563 S VAL VISTA DR STE 108
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85295-6231
Country	:	US
Telephone Number	:	208-447-0803
Fax Number	:

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

Provider Enumeration Date	:	06/13/2016
Last Update Date	:	03/19/2025

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