Provider Demographics
NPI:1386668200
Name:WALLACE, CONNIE LEE (LPCC-S, CTT)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:LEE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPCC-S, CTT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 534
Mailing Address - Street 2:
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663-0534
Mailing Address - Country:US
Mailing Address - Phone:330-343-7400
Mailing Address - Fax:330-343-7414
Practice Address - Street 1:547 1/2 S JAMES ST
Practice Address - Street 2:STE. A
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2137
Practice Address - Country:US
Practice Address - Phone:330-343-7400
Practice Address - Fax:330-343-7414
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0001636-SUPV101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH741212Medicaid