Provider Demographics
NPI:1235999293
Name:WALLACE, DEBORAH FAYE (LCPC LICENSED CLINIC)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:FAYE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCPC LICENSED CLINIC
Other - Prefix:MS
Other - First Name:DEBORAH
Other - Middle Name:FAYE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC MENTAL HEALTH T
Mailing Address - Street 1:17232 PARKSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626
Mailing Address - Country:US
Mailing Address - Phone:217-827-0523
Mailing Address - Fax:
Practice Address - Street 1:18772 RT. 4
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626
Practice Address - Country:US
Practice Address - Phone:217-854-2712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.003816101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional