Provider Demographics
NPI:1255165189
Name:WALLACE, TAYLOR MONTANA
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MONTANA
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 1:36636 COUNTY ROAD 1700
Mailing Address - Street 2:
Mailing Address - City:STONEWALL
Mailing Address - State:OK
Mailing Address - Zip Code:74871-1200
Mailing Address - Country:US
Mailing Address - Phone:316-312-2085
Mailing Address - Fax:
Practice Address - Street 1:602 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3245
Practice Address - Country:US
Practice Address - Phone:316-312-2085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator