Provider Demographics
NPI:1780044123
Name:WALLACE, ANGELA NICOLE (MS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:NICOLE
Last Name:WALLACE
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Gender:F
Credentials:MS, LPC
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Mailing Address - Street 1:5959 S STAPLES ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-3845
Mailing Address - Country:US
Mailing Address - Phone:361-991-3001
Mailing Address - Fax:361-991-3002
Practice Address - Street 1:5959 S STAPLES ST
Practice Address - Street 2:SUITE 210
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-3845
Practice Address - Country:US
Practice Address - Phone:361-991-3001
Practice Address - Fax:361-991-3002
Is Sole Proprietor?:No
Enumeration Date:2016-02-27
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX72163101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional