MEDICARE: KESHAWN WALLACE LPC-ASSOCIATE

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	101YP2500X	Professional Counselor	101414	TX

General Provider Information

NPI Number	:	1407602337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KESHAWN WALLACE LPC-ASSOCIATE

Provider Business Mailing Address
First Line	:	2763 W I 240 SERVICE RD APT 63G
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-3784
Country	:	US
Telephone Number	:	918-986-5918
Fax Number	:

Provider Business Practice Location Address
First Line	:	2763 W I 240 SERVICE RD APT 63G
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-3784
Country	:	US
Telephone Number	:	918-986-5918
Fax Number	:

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

Provider Enumeration Date	:	04/30/2024
Last Update Date	:	03/02/2026

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