Provider Demographics
NPI:1902629199
Name:WALLACE, CHAKIAH ELAINE (LAC)
Entity type:Individual
Prefix:
First Name:CHAKIAH
Middle Name:ELAINE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3965 SYDNEY DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-7791
Mailing Address - Country:US
Mailing Address - Phone:501-438-2870
Mailing Address - Fax:
Practice Address - Street 1:513 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-5329
Practice Address - Country:US
Practice Address - Phone:501-777-5969
Practice Address - Fax:501-379-9791
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-05
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
ARA2411012101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health