Basic Information
| Provider Information | |||||||||
| NPI: | 1659625804 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARVEY | ||||||||
| FirstName: | WALLACE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8918 W 21ST ST N | ||||||||
| Address2: | #200-284 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672051885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166867884 | ||||||||
| FaxNumber: | 3166860036 | ||||||||
| Practice Location | |||||||||
| Address1: | 8911 E ORME ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672072423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166867884 | ||||||||
| FaxNumber: | 3166860036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2012 | ||||||||
| LastUpdateDate: | 11/08/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 391 | KS | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.