Provider Demographics
NPI:1508396789
Name:WALLACE, COURTNEY NICOLE (AUD, CCC-A, F/AAA)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:NICOLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:AUD, CCC-A, F/AAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 7TH ST W APT 515
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-3094
Mailing Address - Country:US
Mailing Address - Phone:630-303-3209
Mailing Address - Fax:
Practice Address - Street 1:2530 CHICAGO AVE STE 450
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4127
Practice Address - Country:US
Practice Address - Phone:612-813-7610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist