Provider Demographics
NPI:1003016320
Name:WALLACE, DONNA K
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:K
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BOCA CHICA BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-7863
Mailing Address - Country:US
Mailing Address - Phone:956-289-7000
Mailing Address - Fax:956-289-7025
Practice Address - Street 1:1901 S 24TH AVE
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-6533
Practice Address - Country:US
Practice Address - Phone:956-289-7000
Practice Address - Fax:956-289-7257
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18857101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health