Provider Demographics
NPI:1437637592
Name:WALLACE, ALEX (MA, LMHC, LPCC)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MA, LMHC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6675 WESSELMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45248
Mailing Address - Country:US
Mailing Address - Phone:513-407-8788
Mailing Address - Fax:513-417-8955
Practice Address - Street 1:3505 CALUMET ROAD
Practice Address - Street 2:
Practice Address - City:LUDLOW FALLS
Practice Address - State:OH
Practice Address - Zip Code:45339
Practice Address - Country:US
Practice Address - Phone:513-407-8878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88000618A101Y00000X
IN39003606A101Y00000X
OHE.2102199101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor