Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist |
NPI | 1639509862 |
---|---|
Provider Name | Theresa Wallis |
First Address | Mcloud, OK 74851-8566 |
Second Address | Shawnee, OK 74801-6917 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/11/2013 |
Last Update Date | 25/11/2013 |