Provider Demographics
NPI:1942406723
Name:WALLACE, JOHANNA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
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 1:305 NE LOOP 820
Mailing Address - Street 2:BUSINESS TOWER 1, SUITE 200
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-7137
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:4100 N SAM HOUSTON PKWY W STE 240
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77086-1466
Practice Address - Country:US
Practice Address - Phone:832-378-6123
Practice Address - Fax:832-253-1181
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8966235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist