Provider Demographics
NPI:1902287808
Name:LUIS, WALLIS MARLEN (MFTC)
Entity type:Individual
Prefix:
First Name:WALLIS
Middle Name:MARLEN
Last Name:LUIS
Suffix:
Gender:F
Credentials:MFTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1427 ROYAL TROON DR
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-5245
Mailing Address - Country:US
Mailing Address - Phone:786-417-5379
Mailing Address - Fax:786-600-3993
Practice Address - Street 1:12101 E 2ND AVE STE 100
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-8328
Practice Address - Country:US
Practice Address - Phone:720-810-4063
Practice Address - Fax:303-364-3932
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0000981101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)