Provider Demographics
NPI:1205286762
Name:WALLACE, RANE PERRY (MS, LPC, LCDC, SAP)
Entity type:Individual
Prefix:MR
First Name:RANE
Middle Name:PERRY
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MS, LPC, LCDC, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4927 BYERS AVE # 212
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-4148
Mailing Address - Country:US
Mailing Address - Phone:682-232-4003
Mailing Address - Fax:
Practice Address - Street 1:4927 BYERS AVE # 212
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-4148
Practice Address - Country:US
Practice Address - Phone:682-232-4003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74425101YP2500X
TX12567101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)