Provider Demographics
NPI:1306224613
Name:WALLACE, TRACIE (LPC)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 EXECUTIVE PARKWAY DR STE 10
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6323
Mailing Address - Country:US
Mailing Address - Phone:314-469-5522
Mailing Address - Fax:314-469-5504
Practice Address - Street 1:1023 EXECUTIVE PARKWAY DR STE 10
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6323
Practice Address - Country:US
Practice Address - Phone:314-469-5522
Practice Address - Fax:314-469-5504
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012029763101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional