Provider Demographics
NPI:1831304922
Name:WALLACE, TERRY EUGENE (CADC)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:EUGENE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 73 BOX 348
Mailing Address - Street 2:
Mailing Address - City:HAWORTH
Mailing Address - State:OK
Mailing Address - Zip Code:74740-9515
Mailing Address - Country:US
Mailing Address - Phone:580-245-2990
Mailing Address - Fax:
Practice Address - Street 1:104 NE AVENUE A
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745
Practice Address - Country:US
Practice Address - Phone:580-286-3301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK71101YA0400X
OK9591601399101YA0400X
OK558101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)