Provider Demographics
NPI:1255116893
Name:WALLACE, MARY (MS, LPC-A)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8603 N LOOP 1604 W APT 5204
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-2646
Mailing Address - Country:US
Mailing Address - Phone:708-979-5163
Mailing Address - Fax:
Practice Address - Street 1:12274 BANDERA RD STE 101
Practice Address - Street 2:
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023-4386
Practice Address - Country:US
Practice Address - Phone:210-396-7609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX91155101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health