Provider Demographics
NPI:1699911990
Name:WALLACE, SHARICE N (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SHARICE
Middle Name:N
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MS
Other - First Name:SHARICE
Other - Middle Name:N
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:20306 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-1339
Mailing Address - Country:US
Mailing Address - Phone:718-464-5544
Mailing Address - Fax:
Practice Address - Street 1:20306 109TH AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-1339
Practice Address - Country:US
Practice Address - Phone:718-464-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-17
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015733-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY015733-1OtherSPEECH LANGUAGE PATHOLOGIST NYS LICENSE