Provider Demographics
NPI:1629141635
Name:WALLACE, LURA (LISW)
Entity Type:Individual
Prefix:MISS
First Name:LURA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300G EL PASEO RD 201
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-6024
Mailing Address - Country:US
Mailing Address - Phone:575-525-0304
Mailing Address - Fax:575-524-4813
Practice Address - Street 1:1990E LOHMAN AVE 204
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3172
Practice Address - Country:US
Practice Address - Phone:575-525-0304
Practice Address - Fax:575-524-4813
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-33621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical