Provider Demographics
NPI:1568898898
Name:WALLACE, NICOLE MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3345 W 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-1909
Mailing Address - Country:US
Mailing Address - Phone:303-500-3407
Mailing Address - Fax:303-835-4500
Practice Address - Street 1:3345 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-1909
Practice Address - Country:US
Practice Address - Phone:303-500-3407
Practice Address - Fax:303-835-4500
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY3627103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist