Provider Demographics
NPI:1548762958
Name:WALLACE, PATRICIA E
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3365 W CRAIG RD STE 25
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-5127
Mailing Address - Country:US
Mailing Address - Phone:702-488-2464
Mailing Address - Fax:702-247-4535
Practice Address - Street 1:3365 W CRAIG RD STE 25
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-5127
Practice Address - Country:US
Practice Address - Phone:702-488-2464
Practice Address - Fax:702-247-4535
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health