Provider Demographics
NPI:1326164278
Name:WALLACE, JUANITA
Entity Type:Individual
Prefix:
First Name:JUANITA
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 1:570 SHACKELFORD RD
Mailing Address - Street 2:ROAD
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-5457
Mailing Address - Country:US
Mailing Address - Phone:314-583-0549
Mailing Address - Fax:
Practice Address - Street 1:570 SHACKELFORD RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-5457
Practice Address - Country:US
Practice Address - Phone:314-583-0549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002006418101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health