Provider Demographics
NPI:1497709703
Name:WALLACE, TERESA (MS, F-AAA)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, F-AAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 RAMBLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-9407
Mailing Address - Country:US
Mailing Address - Phone:717-272-6621
Mailing Address - Fax:717-228-5970
Practice Address - Street 1:1700 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7529
Practice Address - Country:US
Practice Address - Phone:717-272-6621
Practice Address - Fax:717-228-5970
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT005862231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist