| Doctor Name: | WILLIAM WALLACE |
| NPI Number: | 1255765194 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | CRAADC, PLPC |
| License Number: | 6279 |
| Business Practice Address: | 318 S Oak California, MO - 65018 |
| Business Phone Number: | 5737962233 |
| Business Fax Number: | |
| Mailing Address: | 318 S Oak, CALIFORNIA |
| State: | MO |
| Postal Code: | 65018 |
| Phone Number: | 5737962233 |
| Fax Number: | |
| NPI Enumeration Date: | 08/28/2013 |
| NPI Last Update Date: | 04/16/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 6279 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MO |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |