Provider Demographics
NPI:1720755283
Name:WALLACE, ROBIN SUE (SLP)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:SUE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17674 W HIGHWAY 32
Mailing Address - Street 2:
Mailing Address - City:LICKING
Mailing Address - State:MO
Mailing Address - Zip Code:65542-9018
Mailing Address - Country:US
Mailing Address - Phone:573-201-8534
Mailing Address - Fax:
Practice Address - Street 1:17674 W HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:LICKING
Practice Address - State:MO
Practice Address - Zip Code:65542-9018
Practice Address - Country:US
Practice Address - Phone:573-201-8534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021034135235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist