Provider Demographics
NPI:1033532452
Name:WALLACE, ASHLEY D (MS, PLPC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 E BATTLEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-4807
Mailing Address - Country:US
Mailing Address - Phone:417-597-4572
Mailing Address - Fax:
Practice Address - Street 1:777 E BATTLEFIELD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-4807
Practice Address - Country:US
Practice Address - Phone:417-597-4572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014001278101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional