Provider Demographics
NPI:1447932827
Name:WALLS, PRESTON BRICE
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:BRICE
Last Name:WALLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15301 WHITE TAIL LOOP
Mailing Address - Street 2:
Mailing Address - City:MASCOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:34753-9007
Mailing Address - Country:US
Mailing Address - Phone:689-275-4388
Mailing Address - Fax:
Practice Address - Street 1:501 E KENNEDY BLVD STE 1400
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-5246
Practice Address - Country:US
Practice Address - Phone:813-638-0859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst