MEDICARE: MR. NICHOLAS PRESTON WALLACE LPC, NCC, CCMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPC #5493	LA
2	101YP2500X	Professional Counselor	LPC #5493	LA

General Provider Information

NPI Number	:	1356747430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NICHOLAS PRESTON WALLACE LPC, NCC, CCMHC

Provider Business Mailing Address
First Line	:	90 KINGSTON XING APT 1506
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-6289
Country	:	US
Telephone Number	:	318-210-8499
Fax Number	:

Provider Business Practice Location Address
First Line	:	90 KINGSTON XING APT 1506
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-6289
Country	:	US
Telephone Number	:	318-935-0105
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2014
Last Update Date	:	06/06/2021

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