Provider Demographics
NPI:1609511278
Name:WALLACE, MARIE C (LPCC)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4229 BARDSTOWN RD STE 204
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-4271
Mailing Address - Country:US
Mailing Address - Phone:502-936-6546
Mailing Address - Fax:
Practice Address - Street 1:18 BRIAN ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:KY
Practice Address - Zip Code:41008-8202
Practice Address - Country:US
Practice Address - Phone:150-252-5853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY277200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health