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NPI Code Detail

MEDICARE: TARKISHA WALLACE LPC-S, NCC

MEDICARE: TARKISHA WALLACE LPC-S, NCC
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
1101YP2500XProfessional Counselor4405LA

General Provider Information

NPI Number : 1407233505
Entity Type Code : Individual
Provider Name (Legal Business Name) : TARKISHA WALLACE LPC-S, NCC
Provider Business Mailing Address
First Line : 1000 CHINABERRY DR STE 902
Second Line :
City : BOSSIER CITY
State : LA
Zip : 71111-2455
Country : US
Telephone Number : 318-742-3408
Fax Number :
Provider Business Practice Location Address
First Line : 1000 CHINABERRY DR STE 902
Second Line :
City : BOSSIER CITY
State : LA
Zip : 71111-2455
Country : US
Telephone Number : 318-742-3408
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/28/2015
Last Update Date : 09/06/2019

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