Provider Demographics
NPI:1164854253
Name:WALLACE, PATTY
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 S ANN BLVD
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-1254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1007 S ANN BLVD
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-1254
Practice Address - Country:US
Practice Address - Phone:254-773-6787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist