Provider Demographics
NPI:1659400471
Name:WALLACE, DIANE (SLP)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11150 MONTWOOD DRIVE
Mailing Address - Street 2:BLDG A.
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936
Mailing Address - Country:US
Mailing Address - Phone:915-594-0202
Mailing Address - Fax:915-591-2116
Practice Address - Street 1:11150 MONTWOOD DRIVE
Practice Address - Street 2:BLDG A.
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936
Practice Address - Country:US
Practice Address - Phone:915-594-0202
Practice Address - Fax:915-591-2116
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14445235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004638502Medicaid