Provider Demographics
NPI:1952164063
Name:A WALLACE MENTAL HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:A WALLACE MENTAL HEALTH SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDREA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, PHMPN-BC
Authorized Official - Phone:210-836-7593
Mailing Address - Street 1:8604 CLIPPER HBR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-6753
Mailing Address - Country:US
Mailing Address - Phone:210-836-7593
Mailing Address - Fax:
Practice Address - Street 1:4241 E PIEDRAS DR STE 118
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-1422
Practice Address - Country:US
Practice Address - Phone:210-301-0031
Practice Address - Fax:210-301-0031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-01
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty