Provider Demographics
NPI:1750834248
Name:WALLACE LEBAR, KATHERINE (LPC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:WALLACE LEBAR
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 N 21ST ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-3218
Mailing Address - Country:US
Mailing Address - Phone:208-340-5622
Mailing Address - Fax:
Practice Address - Street 1:1109 N 21ST ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-3218
Practice Address - Country:US
Practice Address - Phone:208-340-5622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6155101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional