| NPI | 1619300605 |
|---|---|
| Former Name | LISA WALLACE |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: IL 180.008731) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: IL 180.008731) |
| 101YP2500X Counselor, Professional (Licence: IL 180.008731) | |
| 101YP2500X Counselor, Professional (Licence: MD Lc11094) | |
| Enumeration Date | 2013-08-14 |
| Last Update Date | 2021-02-01 |