Provider Demographics
NPI:1003321720
Name:WALLACE, DARRE'LL J
Entity type:Individual
Prefix:
First Name:DARRE'LL
Middle Name:J
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 1:1711 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4139
Mailing Address - Country:US
Mailing Address - Phone:318-226-9944
Mailing Address - Fax:318-226-9942
Practice Address - Street 1:1711 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4139
Practice Address - Country:US
Practice Address - Phone:318-226-9944
Practice Address - Fax:318-226-9942
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health