Provider Demographics
NPI:1720886567
Name:WALLACE, KIMBERLY DEVAGHUN (MA, LPC, LCDC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DEVAGHUN
Last Name:WALLACE
Suffix:
Gender:
Credentials:MA, LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 FAIRDALE ESTATES CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-2374
Mailing Address - Country:US
Mailing Address - Phone:904-860-4443
Mailing Address - Fax:
Practice Address - Street 1:1775 SAINT JAMES PL STE 325
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77056-3416
Practice Address - Country:US
Practice Address - Phone:713-730-9783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX92479101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health