Provider Demographics
NPI:1629177480
Name:WALLACE, APRIL D (PSYD)
Entity Type:Individual
Prefix:
First Name:APRIL
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-4117
Mailing Address - Country:US
Mailing Address - Phone:715-483-3221
Mailing Address - Fax:715-483-0507
Practice Address - Street 1:235 E STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-4117
Practice Address - Country:US
Practice Address - Phone:715-483-3221
Practice Address - Fax:715-483-0507
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2189-057103T00000X
MNLP2603103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0413704OtherMEDICA
WI2189057OtherWI STATE LICENSE
MN27G52WAOtherBLUE CROSS FACILITY
HP27845OtherHEALTHPARTNERS
WI39129500Medicaid
WI47386934001OtherWI BLUE CROSS
474668299OtherCHAMPUS TRICARE
MN64Q42WAOtherBLUE CROSS PRO FEE
MNLP2603OtherMN STATE LICENSE
MN596713900Medicaid
680012001OtherRAILROAD MEDICARE
NA9031022307OtherPREFERREDONE