Provider Demographics
NPI:1275902462
Name:WALLACE, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
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 1:111 W ANDERSON LN
Mailing Address - Street 2:SUITE D197
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752-1132
Mailing Address - Country:US
Mailing Address - Phone:508-932-8926
Mailing Address - Fax:
Practice Address - Street 1:111 W ANDERSON LN
Practice Address - Street 2:SUITE D197
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-1132
Practice Address - Country:US
Practice Address - Phone:508-932-8926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71945101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional