Provider Demographics
NPI:1477887826
Name:KEELING-WALLACE, VICKIE RENEE (MA)
Entity Type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:RENEE
Last Name:KEELING-WALLACE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 BITTERSWEET CT.
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203
Mailing Address - Country:US
Mailing Address - Phone:573-823-3878
Mailing Address - Fax:
Practice Address - Street 1:3407 BERRYWOOD DR
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6500
Practice Address - Country:US
Practice Address - Phone:573-443-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000891101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional