Provider Demographics
NPI:1215088554
Name:WALLIS, CARY N (PSYD)
Entity type:Individual
Prefix:DR
First Name:CARY
Middle Name:N
Last Name:WALLIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3038 PENROSE PL
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-6718
Mailing Address - Country:US
Mailing Address - Phone:513-484-5655
Mailing Address - Fax:
Practice Address - Street 1:800 COMPTON RD UNIT 1
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45231-3846
Practice Address - Country:US
Practice Address - Phone:513-521-4405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1430103TC0700X
OH6252103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical