Provider Demographics
NPI:1114767837
Name:WALLACE, ASHLI KEANAN
Entity type:Individual
Prefix:
First Name:ASHLI
Middle Name:KEANAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 ESSEX LN
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1425
Mailing Address - Country:US
Mailing Address - Phone:808-778-0777
Mailing Address - Fax:
Practice Address - Street 1:2107 ESSEX LN
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1425
Practice Address - Country:US
Practice Address - Phone:808-778-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAC-1241-33397408101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor