Basic Information
| Provider Information | |||||||||
| NPI: | 1003016320 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 BOCA CHICA BLVD STE 5 | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785207863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9562897000 | ||||||||
| FaxNumber: | 9562897025 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 S 24TH AVE | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785396533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9562897000 | ||||||||
| FaxNumber: | 9562897257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2007 | ||||||||
| LastUpdateDate: | 07/24/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 18857 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.