Provider Demographics
NPI:1003385170
Name:WALLACE, MEGAN NICOL (SLP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:NICOL
Last Name:WALLACE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:NICOL
Other - Last Name:SALES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1628 19TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79401-4895
Mailing Address - Country:US
Mailing Address - Phone:806-219-0500
Mailing Address - Fax:806-766-1286
Practice Address - Street 1:1628 19TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79401-4895
Practice Address - Country:US
Practice Address - Phone:806-219-0500
Practice Address - Fax:806-766-1286
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113791235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist