Provider Demographics
NPI:1952820292
Name:WALLACE, VICTORIA LYNN
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LYNN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 BONNYMEDE RD APT 104
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1313
Mailing Address - Country:US
Mailing Address - Phone:720-985-4453
Mailing Address - Fax:
Practice Address - Street 1:79 BONNYMEDE RD
Practice Address - Street 2:APT 104
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-8100
Practice Address - Country:US
Practice Address - Phone:720-985-4453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)