Provider Demographics
NPI:1053359208
Name:WALLIS, CLINTON BARRETT (OT)
Entity type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:BARRETT
Last Name:WALLIS
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 DOWNTOWNER LOOP W
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-5503
Mailing Address - Country:US
Mailing Address - Phone:251-380-1111
Mailing Address - Fax:251-380-1110
Practice Address - Street 1:709 DOWNTOWNER LOOP W
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-5503
Practice Address - Country:US
Practice Address - Phone:251-380-1111
Practice Address - Fax:251-380-1110
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2224174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51514463OtherBCBS PROVIDER NUMBER