Provider Demographics
NPI:1699030189
Name:WALLIS, ASHLEY E (MS)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:E
Last Name:WALLIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WASHINGTON AVENUE EXT.
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203
Mailing Address - Country:US
Mailing Address - Phone:518-218-0000
Mailing Address - Fax:518-862-2175
Practice Address - Street 1:300 WASHINGTON AVENUE EXT.
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203
Practice Address - Country:US
Practice Address - Phone:518-218-0000
Practice Address - Fax:518-862-2175
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1740206010OtherGROUP NPI