MEDICARE: MRS. ANNETTE S. WALLACE LPC

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	2020	OK

General Provider Information

NPI Number	:	1952698235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANNETTE S. WALLACE LPC

Provider Business Mailing Address
First Line	:	9066 S. 264TH E. AVE.
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74014
Country	:	US
Telephone Number	:	918-645-7853
Fax Number	:

Provider Business Practice Location Address
First Line	:	6931 S 66TH EAST AVE
Second Line	:	115
City	:	TULSA
State	:	OK
Zip	:	74133-1754
Country	:	US
Telephone Number	:	918-645-7853
Fax Number	:

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

Provider Enumeration Date	:	07/07/2011
Last Update Date	:	07/07/2011

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