Provider Demographics
NPI:1124743984
Name:WALLACE, LORAN PAIGE (LPC)
Entity type:Individual
Prefix:
First Name:LORAN
Middle Name:PAIGE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7720 E HEATHERBRAE AVE UNIT 23
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-4052
Mailing Address - Country:US
Mailing Address - Phone:281-714-5779
Mailing Address - Fax:
Practice Address - Street 1:10613 N HAYDEN RD STE J-103
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-5683
Practice Address - Country:US
Practice Address - Phone:281-714-5779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-21109101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health