Provider Demographics
NPI:1104033513
Name:WALLACE, ELIZABETH (PHD, CCC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHD, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8215 WESTCHESTER DR
Mailing Address - Street 2:SUITE 234
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-6103
Mailing Address - Country:US
Mailing Address - Phone:214-368-8251
Mailing Address - Fax:214-368-7765
Practice Address - Street 1:8215 WESTCHESTER DRIVE
Practice Address - Street 2:SUITE 234
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-6103
Practice Address - Country:US
Practice Address - Phone:214-368-8251
Practice Address - Fax:214-368-7765
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14038235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX52-8016Medicare ID - Type Unspecified