Provider Demographics
NPI:1578183364
Name:WALLACE, AUNDERIA DENISE
Entity Type:Individual
Prefix:MRS
First Name:AUNDERIA
Middle Name:DENISE
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 1:535 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60104-1733
Mailing Address - Country:US
Mailing Address - Phone:708-267-4044
Mailing Address - Fax:
Practice Address - Street 1:535 49TH AVE
Practice Address - Street 2:
Practice Address - City:BELLWOOD
Practice Address - State:IL
Practice Address - Zip Code:60104-1733
Practice Address - Country:US
Practice Address - Phone:708-267-4044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health