Provider Demographics
NPI:1639480627
Name:WALLACE, SHAYLA (MSP, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHAYLA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-6471
Mailing Address - Country:US
Mailing Address - Phone:803-840-3411
Mailing Address - Fax:
Practice Address - Street 1:5 DOWD CIR
Practice Address - Street 2:SUITE A
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-7901
Practice Address - Country:US
Practice Address - Phone:910-295-2609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9030235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist