Provider Demographics
NPI:1134525637
Name:WALLACE, LINDSAY ALLISON
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:ALLISON
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 1:1574 SHERIDAN AVE NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-3970
Mailing Address - Country:US
Mailing Address - Phone:330-647-8771
Mailing Address - Fax:
Practice Address - Street 1:1574 SHERIDAN AVE NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-3970
Practice Address - Country:US
Practice Address - Phone:330-647-8771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.9742235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist