Provider Demographics
NPI:1063783462
Name:WALLIS, TINA MARIE (LPC, CPCS)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:WALLIS
Suffix:
Gender:F
Credentials:LPC, CPCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 WATERFRONT PARK CT
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-5772
Mailing Address - Country:US
Mailing Address - Phone:706-490-9204
Mailing Address - Fax:
Practice Address - Street 1:12 WATERFRONT PARK CT
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-5772
Practice Address - Country:US
Practice Address - Phone:706-490-9204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006897101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional