Provider Demographics
NPI:1396066759
Name:WALLACE, EBONY VACH'E
Entity type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:VACH'E
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 1:12123 QUEENS RIVER DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77044-5344
Mailing Address - Country:US
Mailing Address - Phone:832-298-8987
Mailing Address - Fax:
Practice Address - Street 1:12123 QUEENS RIVER DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77044-5344
Practice Address - Country:US
Practice Address - Phone:832-298-8987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator