Provider Demographics
NPI:1154507820
Name:WALLACE, KATHLEEN PETERSON (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:PETERSON
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 MCLILLIE LN
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019-6413
Mailing Address - Country:US
Mailing Address - Phone:901-476-7918
Mailing Address - Fax:
Practice Address - Street 1:425 MCLILLIE LN
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-6413
Practice Address - Country:US
Practice Address - Phone:901-476-7918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-12
Last Update Date:2008-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP 0000000512235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist