Provider Demographics
NPI:1255821286
Name:WALLACE, ALICIA D (LPC)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9021 BENEVOLENT CT
Mailing Address - Street 2:
Mailing Address - City:AUBREY
Mailing Address - State:TX
Mailing Address - Zip Code:76227-1303
Mailing Address - Country:US
Mailing Address - Phone:903-821-8786
Mailing Address - Fax:
Practice Address - Street 1:3312 TEASLEY LN
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-8311
Practice Address - Country:US
Practice Address - Phone:402-222-3999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74421101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX74421OtherTEXAS STATE BOARD OF EXAMINERS OF PROFESSIONAL COUNSELORS