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General NPI Number Information
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NPI Number | 1114319092
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Entity Type | Individual
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Provider Name | KATHI WALLACE L.C.P.C.
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Gender | Female
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Dates
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Enumeration Date | 03/02/2015
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Last Update Date | 02/02/2022
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Provider Practice Location Address
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Address Line | 5 SCHIBER CT STE D
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City | MARYVILLE
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State | IL
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Zip | 62062-5606
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Country | US
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Telephone | 314-626-4285
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Fax |
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Provider Business Mailing Address
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Address Line | 27 WINDERMERE DR
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City | GLEN CARBON
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State | IL
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Zip | 62034-1477
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Country | US
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Telephone | 314-626-4285
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 2013036985
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | IL#180.009256
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180.009256
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License Number State | IL
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