Provider Demographics
NPI:1942583893
Name:WALLACE, KATHERINE SUE (MS)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:SUE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 S GIDEON AVE
Mailing Address - Street 2:
Mailing Address - City:GIDEON
Mailing Address - State:MO
Mailing Address - Zip Code:63848-9200
Mailing Address - Country:US
Mailing Address - Phone:573-370-2129
Mailing Address - Fax:
Practice Address - Street 1:408 S GIDEON AVE
Practice Address - Street 2:
Practice Address - City:GIDEON
Practice Address - State:MO
Practice Address - Zip Code:63848-9200
Practice Address - Country:US
Practice Address - Phone:573-370-2129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO6385101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)