Provider Demographics
NPI:1205373107
Name:WALLACE, JUDITH (MAC, LAT)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MAC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2701
Mailing Address - Country:US
Mailing Address - Phone:307-674-4405
Mailing Address - Fax:
Practice Address - Street 1:1221 W 5TH ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2701
Practice Address - Country:US
Practice Address - Phone:307-674-4405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY352101YA0400X
WYA-030171100000X
WY1359101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171100000XOther Service ProvidersAcupuncturist