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General NPI Number Information
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NPI Number | 1730628074
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Entity Type | Individual
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Provider Name | FANNIE BEATRICE WALLACE LPC
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Gender | Female
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Dates
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Enumeration Date | 02/20/2017
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Last Update Date | 04/25/2025
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Provider Practice Location Address
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Address Line | 180 MEDICAL PARK PL
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City | HOT SPRINGS
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State | AR
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Zip | 71901-8065
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Country | US
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Telephone | 501-521-1942
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Fax | 501-359-3010
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Provider Business Mailing Address
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Address Line | PO BOX 497
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City | AUGUSTA
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State | AR
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Zip | 72006-0497
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Country | US
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Telephone | 870-347-2534
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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 | A2005077
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License Number State | AR
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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 | P2205002
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License Number State | AR
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