Doctor Name: | KATHI WALLACE |
NPI Number: | 1114319092 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | M.A.; L.C.P.C. |
License Number: | IL#180.009256 |
Business Practice Address: | 11166 Tesson Ferry Rd. Suite #203 Alpha Omega Christian Counseling St. Louis, MO - 63123 |
Business Phone Number: | 3148492120 |
Business Fax Number: | 3147291953 |
Mailing Address: | 11166 Tesson Ferry Rd., Suite #203 Alpha Omega Christian Counseling ST. LOUIS |
State: | MO |
Postal Code: | 63123 |
Phone Number: | 3148492120 |
Fax Number: | 3147291953 |
NPI Enumeration Date: | 03/02/2015 |
NPI Last Update Date: | 03/02/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YP2500X |
License Number: | IL#180.009256 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IL |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Professional |
Taxonomy Definition: |