Provider Demographics
NPI:1255765194
Name:WALLACE, WILLIAM (CRAADC, PLPC)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CRAADC, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 S OAK
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MO
Mailing Address - Zip Code:65018
Mailing Address - Country:US
Mailing Address - Phone:573-796-2233
Mailing Address - Fax:
Practice Address - Street 1:318 S OAK
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MO
Practice Address - Zip Code:65018
Practice Address - Country:US
Practice Address - Phone:573-796-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO6279101YA0400X
MO2013038285101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)