| Doctor Name: | TINA MARIE WALLIS |
| NPI Number: | 1063783462 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LPC, CPCS |
| License Number: | 006897 |
| Business Practice Address: | 12 Waterfront Park Ct Dawsonville, GA - 305345772 |
| Business Phone Number: | 7064909204 |
| Business Fax Number: | |
| Mailing Address: | 12 Waterfront Park Ct, DAWSONVILLE |
| State: | GA |
| Postal Code: | 305345772 |
| Phone Number: | 7064909204 |
| Fax Number: | |
| NPI Enumeration Date: | 01/18/2012 |
| NPI Last Update Date: | 12/17/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | 006897 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |