Healthcare Provider Details

I. General information

NPI: 1710810718
Provider Name (Legal Business Name): DANA WALLACE PHD, LPC-S, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 RUE BEAUREGARD # 202
LAFAYETTE LA
70508-3251
US

IV. Provider business mailing address

900 CAMP ST
NEW ORLEANS LA
70130-3971
US

V. Phone/Fax

Practice location:
  • Phone: 504-318-6813
  • Fax:
Mailing address:
  • Phone: 504-318-6813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7071
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: