Provider Demographics
NPI:1760958458
Name:WALLACE, LISA (LCSW, LCDC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2903 GABRIEL VIEW DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-2707
Mailing Address - Country:US
Mailing Address - Phone:512-869-9254
Mailing Address - Fax:
Practice Address - Street 1:2903 GABRIEL VIEW DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-2707
Practice Address - Country:US
Practice Address - Phone:512-869-9254
Practice Address - Fax:512-863-6833
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX585451041C0700X
TX12442101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)