Provider Demographics
NPI:1407620867
Name:WALLACE, ADRIANNE V (MFTLC)
Entity Type:Individual
Prefix:
First Name:ADRIANNE
Middle Name:V
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MFTLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SWEETGRASS AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-2698
Mailing Address - Country:US
Mailing Address - Phone:406-219-7769
Mailing Address - Fax:
Practice Address - Street 1:211 SWEETGRASS AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-2698
Practice Address - Country:US
Practice Address - Phone:406-219-7769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-MFLC-LIC-64874106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist