Healthcare Provider Details

I. General information

NPI: 1730628074
Provider Name (Legal Business Name): FANNIE BEATRICE WALLACE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 MEDICAL PARK PL
HOT SPRINGS AR
71901-8065
US

IV. Provider business mailing address

PO BOX 497
AUGUSTA AR
72006-0497
US

V. Phone/Fax

Practice location:
  • Phone: 501-521-1942
  • Fax: 501-359-3010
Mailing address:
  • Phone: 870-347-2534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA2005077
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2205002
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: