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General NPI Number Information
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NPI Number | 1952820292
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Entity Type | Individual
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Provider Name | VICTORIA LYNN WALLACE
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Gender | Female
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Dates
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Enumeration Date | 09/19/2017
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Last Update Date | 09/19/2017
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Provider Practice Location Address
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Address Line | 79 BONNYMEDE RD APT 104
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City | PUEBLO
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State | CO
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Zip | 81001-8100
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Country | US
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Telephone | 720-985-4453
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Fax |
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Provider Business Mailing Address
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Address Line | 79 BONNYMEDE RD APT 104
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City | PUEBLO
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State | CO
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Zip | 81001-1313
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Country | US
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Telephone | 720-985-4453
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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