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General NPI Number Information
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NPI Number | 1821311606
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Entity Type | Individual
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Provider Name | NICOLE BROADWAY WALLACE LPCC
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Gender | Female
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Dates
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Enumeration Date | 03/08/2010
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Last Update Date | 06/23/2025
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Provider Practice Location Address
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Address Line | 207 BELO DR
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City | KILLEEN
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State | TX
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Zip | 76542-5598
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Country | US
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Telephone | 254-630-7450
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Fax | 254-853-4241
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Provider Business Mailing Address
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Address Line | 2201 S. WS YOUNG DR SUITE 106-C OFFICE 105
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City | KILLEEN
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State | TX
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Zip | 76543
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Country | US
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Telephone | 254-630-7450
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Fax | 254-853-4241
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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 | 19501
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License Number State | TX
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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 | 9626
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License Number State | CA
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