Basic Information
| Provider Information | |||||||||
| NPI: | 1508453655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21226 CASRIL DR | ||||||||
| Address2: | |||||||||
| City: | MANDEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704717614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044910210 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1505 N FLORIDA ST | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704331544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9859001626 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2020 | ||||||||
| LastUpdateDate: | 12/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6914 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.