Provider Demographics
NPI:1114319092
Name:WALLACE, KATHI (LCPC)
Entity Type:Individual
Prefix:
First Name:KATHI
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:JENNIFER
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA; LCPC
Mailing Address - Street 1:27 WINDERMERE DR
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1477
Mailing Address - Country:US
Mailing Address - Phone:314-626-4285
Mailing Address - Fax:
Practice Address - Street 1:5 SCHIBER CT STE D
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5606
Practice Address - Country:US
Practice Address - Phone:314-626-4285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013036985101YP2500X
ILIL#180.009256101YP2500X
IL180.009256101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional