Provider Demographics
NPI:1710241633
Name:WALLACE, JANICE LEIGH (MA, CCC-SLP/L)
Entity Type:Individual
Prefix:MRS
First Name:JANICE
Middle Name:LEIGH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 OLD HOME RD
Mailing Address - Street 2:
Mailing Address - City:EDDYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62928-9734
Mailing Address - Country:US
Mailing Address - Phone:618-672-4300
Mailing Address - Fax:
Practice Address - Street 1:74 OLD HOME RD
Practice Address - Street 2:
Practice Address - City:EDDYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62928-9734
Practice Address - Country:US
Practice Address - Phone:618-672-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008090235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist