Provider Demographics
NPI:1063950764
Name:WALLUS, FAYE (LMFT)
Entity type:Individual
Prefix:
First Name:FAYE
Middle Name:
Last Name:WALLUS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 TECHNOLOGY DR APT 654
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-2930
Mailing Address - Country:US
Mailing Address - Phone:651-503-5968
Mailing Address - Fax:
Practice Address - Street 1:12900 TECHNOLOGY DR APT 654
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-2930
Practice Address - Country:US
Practice Address - Phone:651-503-5968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1162-124106H00000X
MN2579106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist