Provider Demographics
NPI:1518287192
Name:WALLACE-FOSTER, SHAWNA ALEXANDRIA (MS LPC)
Entity Type:Individual
Prefix:MS
First Name:SHAWNA
Middle Name:ALEXANDRIA
Last Name:WALLACE-FOSTER
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7550 AIRWAYS BLVD UNIT 1567
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-6378
Mailing Address - Country:US
Mailing Address - Phone:662-200-7331
Mailing Address - Fax:833-355-5044
Practice Address - Street 1:230 GOODMAN RD E STE 204
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-8313
Practice Address - Country:US
Practice Address - Phone:662-622-1838
Practice Address - Fax:833-355-5044
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-07
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MS2680101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health