MEDICARE: MARY WALLACE M.S, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	91155	TX
2	101YP2500X	Professional Counselor	91155	TX

General Provider Information

NPI Number	:	1255116893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY WALLACE M.S, LPC

Provider Business Mailing Address
First Line	:	8603 N LOOP 1604 W APT 5204
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-2646
Country	:	US
Telephone Number	:	708-979-5163
Fax Number	:

Provider Business Practice Location Address
First Line	:	21252 GATHERING OAK STE 106
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78260-3392
Country	:	US
Telephone Number	:	830-730-6090
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2023
Last Update Date	:	06/22/2025

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