Provider Demographics
NPI:1528848926
Name:WALLACE, STEVEN LANE
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:LANE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9808 WINTHROP DR
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-6106
Mailing Address - Country:US
Mailing Address - Phone:509-593-3322
Mailing Address - Fax:
Practice Address - Street 1:750 GEORGE WASHINGTON WAY STE 8
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4247
Practice Address - Country:US
Practice Address - Phone:509-593-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61453392101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health