1720886567 NPI number — KIMBERLY DEVAGHUN WALLACE MA, LPC, LCDC

Table of content: KIMBERLY DEVAGHUN WALLACE MA, LPC, LCDC (NPI 1720886567)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720886567 NPI number — KIMBERLY DEVAGHUN WALLACE MA, LPC, LCDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
KIMBERLY
Provider Middle Name:
DEVAGHUN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC, LCDC
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:
1720886567
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3002 FAIRDALE ESTATES CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77057-2374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-860-4443
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1775 SAINT JAMES PL STE 325
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77056-3416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-730-9783
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2025

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  92479 , 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)





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