1124002571 NPI number — LISA M WALLACE MA, LPC

Table of content: LISA M WALLACE MA, LPC (NPI 1124002571)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124002571 NPI number — LISA M WALLACE MA, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
LISA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124002571
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 273338
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80527-3338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-817-4049
Provider Business Mailing Address Fax Number:
877-833-4460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4103 E BOARDWALK DRIVE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80525-5930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-817-4049
Provider Business Practice Location Address Fax Number:
877-833-4460
Provider Enumeration Date:
11/30/2005

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: 101YM0800X , with the licence number:  906 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 5913 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 312410 . This is a "BS OF WY" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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