Provider Demographics
NPI:1841088549
Name:WALLACE, JAMES (MA, THM, STM)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:WALLACE
Suffix:
Gender:
Credentials:MA, THM, STM
Other - Prefix:
Other - First Name:JIM
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, THM, STM
Mailing Address - Street 1:854 WEATHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63021-7144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12801 FLUSHING MEADOWS DR STE 250
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1829
Practice Address - Country:US
Practice Address - Phone:314-626-4774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor