Provider Demographics
NPI:1821272550
Name:WALLACE, JOHN H (LPCC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 BAXTER AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-1302
Mailing Address - Country:US
Mailing Address - Phone:513-861-4977
Mailing Address - Fax:
Practice Address - Street 1:5134 CEDAR VILLAGE DR
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-3717
Practice Address - Country:US
Practice Address - Phone:513-229-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0000844101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional