Individual
THERESA WALLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
201 N BROADWAY AVE, SHAWNEE, OK 74801-6917
(580) 748-0342
(405) 386-3213
Mailing address
10800 EASTWAY, MCLOUD, OK 74851-8566
(580) 748-0342
(405) 386-3213
Taxonomy
Speciality
Code
Description
License number
State
103TR0400X
Rehabilitation Psychologist
Primary
—
—
Other
Enumeration date
11/25/2013
Last updated
11/25/2013
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