Provider Demographics
NPI:1730416017
Name:WALLIS, KAREN MARIE (MED, PCC, LCDC III)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:WALLIS
Suffix:
Gender:F
Credentials:MED, PCC, LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44286-0158
Mailing Address - Country:US
Mailing Address - Phone:216-548-0523
Mailing Address - Fax:
Practice Address - Street 1:29325 CHAGRIN BLVD
Practice Address - Street 2:SUITE #102
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4600
Practice Address - Country:US
Practice Address - Phone:216-548-0523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-07
Last Update Date:2009-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH091014101YA0400X
OHE. 0500432101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)