Doctor Name: | MRS. PATRICIA IRENE WALLACE |
NPI Number: | 1043336704 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | LPC,LADC |
License Number: | 3190 |
Business Practice Address: | 104 N 4th St Hugo, OK - 747434003 |
Business Phone Number: | 5803267531 |
Business Fax Number: | 5803262377 |
Mailing Address: | 104 N 4th St, HUGO |
State: | OK |
Postal Code: | 747434003 |
Phone Number: | 5803267531 |
Fax Number: | 5803262377 |
NPI Enumeration Date: | 03/22/2007 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | 3190 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | OK |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |