Provider Demographics
NPI:1629301353
Name:WALLACE, KIMBERLY (LMFT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:STILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:3647 TAHOE CT
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-4152
Mailing Address - Country:US
Mailing Address - Phone:317-363-7266
Mailing Address - Fax:
Practice Address - Street 1:600 E CARMEL DR
Practice Address - Street 2:SUITE 143
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2803
Practice Address - Country:US
Practice Address - Phone:317-730-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270530AMedicaid
IN100270530AMedicaid