Basic Information
| Provider Information | |||||||||
| NPI: | 1740357813 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLIS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PLMHP, PCMSW, MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5646 OHIO ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681044138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088068156 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 S 42ND ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681052909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025533000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 10/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 7196 | NE | N | Behavioral Health & Social Service Providers | Social Worker | 101Y00000X | 11317 | NE | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.