| Doctor Name: | DR. JOHN R. WALLIS |
| NPI Number: | 1023161197 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D.MIN. |
| License Number: | MT1251 |
| Business Practice Address: | 1417 Se 4th St Ft Lauderdale, FL - 333012319 |
| Business Phone Number: | 9544632273 |
| Business Fax Number: | 9547791643 |
| Mailing Address: | 1417 Se 4th St, FT LAUDERDALE |
| State: | FL |
| Postal Code: | 333012319 |
| Phone Number: | 9544632273 |
| Fax Number: | 9547791643 |
| NPI Enumeration Date: | 01/19/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP1600X |
| License Number: | MT1251 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Pastoral |
| Taxonomy Definition: | |