Provider Demographics
NPI:1821567272
Name:MIZELL WALLACE, LINDSEY S (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LINDSEY
Middle Name:S
Last Name:MIZELL WALLACE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 AVENUE E
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138-7627
Mailing Address - Country:US
Mailing Address - Phone:832-799-3386
Mailing Address - Fax:
Practice Address - Street 1:1225 AVENUE E
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138-7627
Practice Address - Country:US
Practice Address - Phone:832-799-3386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR016414235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist