Provider Demographics
NPI:1669731386
Name:WALLIS, JOE (EDS)
Entity type:Individual
Prefix:MR
First Name:JOE
Middle Name:
Last Name:WALLIS
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 NE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-3339
Mailing Address - Country:US
Mailing Address - Phone:352-334-0955
Mailing Address - Fax:
Practice Address - Street 1:605 NE 1ST ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-3339
Practice Address - Country:US
Practice Address - Phone:352-334-0955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health