Provider Demographics
NPI:1952698235
Name:WALLACE, ANNETTE S (LPC)
Entity Type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:S
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9066 S. 264TH E. AVE.
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014
Mailing Address - Country:US
Mailing Address - Phone:918-645-7853
Mailing Address - Fax:
Practice Address - Street 1:6931 S 66TH EAST AVE
Practice Address - Street 2:115
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-1754
Practice Address - Country:US
Practice Address - Phone:918-645-7853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2020101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional