Provider Demographics
NPI:1124215256
Name:WALLACE, SUSAN 'SUZI' (PHD, PT, LPC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN 'SUZI'
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHD, PT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 OAK HOLLOW LANE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903
Mailing Address - Country:US
Mailing Address - Phone:479-651-7413
Mailing Address - Fax:
Practice Address - Street 1:5111 ROGERS AVENUE, SUITE 533
Practice Address - Street 2:CENTRAL MALL PLAZA SUITES #533
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903
Practice Address - Country:US
Practice Address - Phone:479-651-7413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0510074101YP2500X
AR1724225100000X
AR18-08P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist