Provider Demographics
NPI:1548811961
Name:WALLIS, SPENCER (LMFT)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:WALLIS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15753
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-0753
Mailing Address - Country:US
Mailing Address - Phone:206-605-8473
Mailing Address - Fax:
Practice Address - Street 1:5339 ROOSEVELT WAY NE STE A
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3635
Practice Address - Country:US
Practice Address - Phone:206-605-8473
Practice Address - Fax:206-590-8281
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF60985500106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist