Healthcare Provider Details

I. General information

NPI: 1083256234
Provider Name (Legal Business Name): AIMEE ROSE WALLACE MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 OLIVE ST STE 400
SAINT LOUIS MO
63103-2303
US

IV. Provider business mailing address

1430 OLIVE ST STE 400
SAINT LOUIS MO
63103-2303
US

V. Phone/Fax

Practice location:
  • Phone: 314-206-3700
  • Fax: 314-206-3708
Mailing address:
  • Phone: 314-206-3700
  • Fax: 314-206-3708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2022020122
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: