Healthcare Provider Details

I. General information

NPI: 1972908010
Provider Name (Legal Business Name): AMANDA JO WALLACE PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2014
Last Update Date: 10/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3318
US

IV. Provider business mailing address

1500 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3318
US

V. Phone/Fax

Practice location:
  • Phone: 573-778-4122
  • Fax:
Mailing address:
  • Phone: 573-778-4122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2009031094
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number2009031094
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: