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General NPI Number Information
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NPI Number | 1114767837
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Entity Type | Individual
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Provider Name | ASHLI KEANAN WALLACE
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Gender | Female
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Dates
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Enumeration Date | 05/30/2024
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Last Update Date | 01/02/2025
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Provider Practice Location Address
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Address Line | 2107 ESSEX LN
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City | COLORADO SPRINGS
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State | CO
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Zip | 80909-1425
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Country | US
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Telephone | 808-778-0777
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Fax |
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Provider Business Mailing Address
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Address Line | 2107 ESSEX LN
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City | COLORADO SPRINGS
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State | CO
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Zip | 80909-1425
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Country | US
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Telephone | 808-778-0777
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | AC-1241-33397408
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License Number State | CO
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