1821311606 NPI number — NICOLE BROADWAY WALLACE LPC

Table of content: NICOLE BROADWAY WALLACE LPC (NPI 1821311606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821311606 NPI number — NICOLE BROADWAY WALLACE LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
NICOLE
Provider Middle Name:
BROADWAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROADWAY
Provider Other First Name:
NICOLE
Provider Other Middle Name:
JANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821311606
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2201 S. WS YOUNG DR
Provider Second Line Business Mailing Address:
SUITE 106-C OFFICE 105
Provider Business Mailing Address City Name:
KILLEEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-630-7450
Provider Business Mailing Address Fax Number:
254-853-4241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 BELO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KILLEEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76542-5598
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-630-7450
Provider Business Practice Location Address Fax Number:
254-853-4241
Provider Enumeration Date:
03/08/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  19501 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)