Basic Information
| Provider Information | |||||||||
| NPI: | 1942406723 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | JOHANNA | ||||||||
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| Credential: | MS CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 NE LOOP 820 | ||||||||
| Address2: | BUSINESS TOWER 1, SUITE 200 | ||||||||
| City: | HURST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760537137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172928787 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 N SAM HOUSTON PKWY W STE 240 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770861466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323786123 | ||||||||
| FaxNumber: | 8322531181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA8966 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.