Basic Information
| Provider Information | |||||||||
| NPI: | 1639480627 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | SHAYLA | ||||||||
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| Credential: | MSP, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHERN PINES | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283876471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038403411 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 DOWD CIR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283747901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102952609 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2010 | ||||||||
| LastUpdateDate: | 06/24/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 9030 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.