Provider Demographics
NPI:1073175188
Name:WALLACE, KAY L (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 MARK DR
Mailing Address - Street 2:
Mailing Address - City:GERING
Mailing Address - State:NE
Mailing Address - Zip Code:69341-3874
Mailing Address - Country:US
Mailing Address - Phone:308-631-8259
Mailing Address - Fax:
Practice Address - Street 1:111 W 36TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4636
Practice Address - Country:US
Practice Address - Phone:308-635-2019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE818235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist