Kenneth C Wallis, M.D.

Primary specialty

Psychiatry PhysicianTaxonomy code 2084P0800X

License

811674181205 Issued in UT

Practice address

1260 Lake Blvd
Suite #214
Davis, CA 95616-2614

Phone

(530) 771-2308

Fax

(530) 771-2309

NPI assigned

Feb 9, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Valley Behavioral Health Incorporated

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • West Valley City, UT
  • NPI 1932166980

  Psychiatry

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1139443200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1625788800000",
    "number": "1649243692",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1260 LAKE BLVD",
            "address_2": "SUITE #214",
            "city": "DAVIS",
            "state": "CA",
            "postal_code": "956162614",
            "telephone_number": "530-771-2308",
            "fax_number": "530-771-2309"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1260 LAKE BLVD",
            "address_2": "SUITE #214",
            "city": "DAVIS",
            "state": "CA",
            "postal_code": "956162614",
            "telephone_number": "530-771-2308",
            "fax_number": "530-771-2309"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "40925 County Center Dr Ste 2002nd",
            "address_purpose": "LOCATION",
            "city": "Temecula",
            "state": "CA",
            "postal_code": "925916054",
            "country_code": "US",
            "telephone_number": "951-600-6300",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLIS",
        "first_name": "KENNETH",
        "middle_name": "C",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-02-09",
        "last_updated": "2021-07-09",
        "certification_date": "2021-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "CA",
            "license": "C-41960",
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "UT",
            "license": "811674181205",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "INTRMTN. HEALTH CARE",
            "identifier": "107005564101",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DESERET MUTUAL",
            "identifier": "261795",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EDUCATORS MUTUAL",
            "identifier": "942938348WA1",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Charles Clinton Walker, M.D.
• Louise Phinizy Walker, MFT
• Peri Ashley Walker, MS.,CCC-SLP
• Vivian M Walker, FNP
• Kim Eugene Wallace, D.D.S.
• David T. Walters, MD
• Kayla Jackie Brenya Walton
• Ashley C Wang, PHARM D.
• Erjun Wang, M.D.
• Jeffrey Gary Wang, DPT

• Psychiatry Physician in Davis, CA
• Providers in Davis, CA by specialty
• Psychiatry Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.