MEDICARE: CASEY WALLIS LCPC

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	101YP2500X	Professional Counselor	03938	KS

General Provider Information

NPI Number	:	1669002747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASEY WALLIS LCPC

Provider Business Mailing Address
First Line	:	32 S MIRIAM ST APT 6
Second Line	:
City	:	CLAYCOMO
State	:	MO
Zip	:	64119-3141
Country	:	US
Telephone Number	:	816-701-9519
Fax Number	:

Provider Business Practice Location Address
First Line	:	32 S MIRIAM ST APT 6
Second Line	:
City	:	CLAYCOMO
State	:	MO
Zip	:	64119-3141
Country	:	US
Telephone Number	:	816-701-9519
Fax Number	:

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

Provider Enumeration Date	:	01/17/2020
Last Update Date	:	03/27/2025

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