Provider Demographics
NPI:1518121847
Name:WALLACE, APRIL REED (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:APRIL
Middle Name:REED
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 YOCONA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-6904
Mailing Address - Country:US
Mailing Address - Phone:662-832-4086
Mailing Address - Fax:
Practice Address - Street 1:120 VETERANS DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-3578
Practice Address - Country:US
Practice Address - Phone:662-232-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2011-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000003185235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000003185OtherTN LISENCE TO PRACTICE
MSS3237OtherSTATE LICENSE