Provider Demographics
NPI:1457482903
Name:WALLACE, BRENDA (SLP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 GIRARD BLVD NE
Mailing Address - Street 2:JEFFERSON MS
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2714
Mailing Address - Country:US
Mailing Address - Phone:505-255-2334
Mailing Address - Fax:
Practice Address - Street 1:712 GIRARD BLVD NE
Practice Address - Street 2:JEFFERSON MS
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2714
Practice Address - Country:US
Practice Address - Phone:505-255-2334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1338235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ 5039Medicaid