Healthcare Provider Details

I. General information

NPI: 1780725762
Provider Name (Legal Business Name): JOYCE R WALLACE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NW SOUTH OUTER RD STE 310
BLUE SPRINGS MO
64015-3072
US

IV. Provider business mailing address

1200 NW SOUTH OUTER RD STE 310
BLUE SPRINGS MO
64015-3072
US

V. Phone/Fax

Practice location:
  • Phone: 816-224-0242
  • Fax: 816-224-0454
Mailing address:
  • Phone: 816-224-0242
  • Fax: 816-224-0454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number01709
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: