Provider Demographics
NPI:1730074378
Name:WALLACE, AMBER (CIT)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9171 COCKERHAM RD
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-2255
Mailing Address - Country:US
Mailing Address - Phone:225-924-1910
Mailing Address - Fax:225-924-1910
Practice Address - Street 1:9171 COCKERHAM RD
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-2255
Practice Address - Country:US
Practice Address - Phone:225-924-1910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5772101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)