Provider Demographics
NPI:1396028544
Name:WALLACE COUNSELING, LLC
Entity Type:Organization
Organization Name:WALLACE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIVATE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:970-817-4049
Mailing Address - Street 1:PO BOX 273338
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80527-3338
Mailing Address - Country:US
Mailing Address - Phone:970-817-4049
Mailing Address - Fax:877-833-4460
Practice Address - Street 1:4115 BOARDWALK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5945
Practice Address - Country:US
Practice Address - Phone:970-817-4049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-23
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5913101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty