Provider Demographics
NPI:1063742922
Name:WALLACE, LOU ANN CAREY (SR PSYC EXAMINER)
Entity type:Individual
Prefix:
First Name:LOU ANN
Middle Name:CAREY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:SR PSYC EXAMINER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 205
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:TN
Mailing Address - Zip Code:38363-0205
Mailing Address - Country:US
Mailing Address - Phone:731-549-4382
Mailing Address - Fax:
Practice Address - Street 1:35 JEANNIE BELLE YARBORO RD
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:TN
Practice Address - Zip Code:38363-3305
Practice Address - Country:US
Practice Address - Phone:731-549-4382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-28
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPE0000001013103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical