Provider Demographics
NPI:1396945986
Name:WALLIS, LANDON LEIGH (MS,CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:LANDON
Middle Name:LEIGH
Last Name:WALLIS
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:MRS
Other - First Name:LANDON
Other - Middle Name:LEIGH
Other - Last Name:RUTHERFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,CCC-SLP
Mailing Address - Street 1:112 OLD LAKE CV
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-7637
Mailing Address - Country:US
Mailing Address - Phone:662-891-2029
Mailing Address - Fax:
Practice Address - Street 1:112 OLD LAKE CV
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-7637
Practice Address - Country:US
Practice Address - Phone:662-891-2029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3022235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0020229Medicaid