Provider Demographics
NPI:1679511034
Name:WILL-WALLACE, LOUISE ANN (PHD)
Entity Type:Individual
Prefix:
First Name:LOUISE
Middle Name:ANN
Last Name:WILL-WALLACE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LOUISE
Other - Middle Name:ANN
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:21 CRAWFORD QUARRY RD STE 4
Mailing Address - Street 2:
Mailing Address - City:FALLING WATERS
Mailing Address - State:WV
Mailing Address - Zip Code:25419-4695
Mailing Address - Country:US
Mailing Address - Phone:803-422-0792
Mailing Address - Fax:
Practice Address - Street 1:21 CRAWFORD QUARRY RD STE 4
Practice Address - Street 2:
Practice Address - City:FALLING WATERS
Practice Address - State:WV
Practice Address - Zip Code:25419-4695
Practice Address - Country:US
Practice Address - Phone:803-422-0792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC499103TC0700X
WV1081103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical