Provider Demographics
NPI:1083256234
Name:WALLACE, AIMEE ROSE (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:AIMEE
Middle Name:ROSE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 OLIVE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-2303
Mailing Address - Country:US
Mailing Address - Phone:314-206-3700
Mailing Address - Fax:314-206-3708
Practice Address - Street 1:1430 OLIVE ST STE 400
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2303
Practice Address - Country:US
Practice Address - Phone:314-206-3700
Practice Address - Fax:314-206-3708
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
2022020122101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)