Provider Demographics
NPI:1427440387
Name:WALLACE, COLLEEN BRIDGET (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:BRIDGET
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 ROMIG PL
Mailing Address - Street 2:# 406
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-1680
Mailing Address - Country:US
Mailing Address - Phone:505-489-7764
Mailing Address - Fax:
Practice Address - Street 1:4050 LAKE OTIS PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5223
Practice Address - Country:US
Practice Address - Phone:505-489-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-02
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK489235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1031087Medicaid