Provider Demographics
NPI:1750044327
Name:WALLACE, TINA LOUISE (ALC)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:LOUISE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HIGHWAY 78 W
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-3655
Mailing Address - Country:US
Mailing Address - Phone:205-512-1260
Mailing Address - Fax:844-269-8087
Practice Address - Street 1:1000 HIGHWAY 78 W
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-3655
Practice Address - Country:US
Practice Address - Phone:205-512-1260
Practice Address - Fax:844-269-8087
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3541235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist