Provider Demographics
NPI:1659625804
Name:HARVEY, WALLACE E (LAC)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:E
Last Name:HARVEY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8918 W 21ST ST N
Mailing Address - Street 2:#200-284
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1885
Mailing Address - Country:US
Mailing Address - Phone:316-686-7884
Mailing Address - Fax:316-686-0036
Practice Address - Street 1:8911 E ORME ST
Practice Address - Street 2:SUITE A
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-2423
Practice Address - Country:US
Practice Address - Phone:316-686-7884
Practice Address - Fax:316-686-0036
Is Sole Proprietor?:No
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS391101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)