Provider Demographics
NPI:1326717208
Name:WALLACE, ANGELLA MESHELLE (MS, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:ANGELLA
Middle Name:MESHELLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SILBURY DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-3936
Mailing Address - Country:US
Mailing Address - Phone:818-667-0195
Mailing Address - Fax:
Practice Address - Street 1:4000 S IH 35
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7420
Practice Address - Country:US
Practice Address - Phone:512-414-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108141235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist