Deborah Faye Wallace, LCPC LICENSED CLINIC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

180.003816 Issued in IL

Practice address

18772 RT. 4
Carlinville, IL 62626

Phone

(217) 854-2712

NPI assigned

Mar 19, 2024

Last updated

Mar 19, 2024By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Ms. Deborah Faye Wallace Other name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1710806400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1710806400000",
    "number": "1235999293",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17232 PARKSIDE DRIVE",
            "city": "CARLINVILLE",
            "state": "IL",
            "postal_code": "62626",
            "telephone_number": "217-827-0523"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18772 RT. 4",
            "city": "CARLINVILLE",
            "state": "IL",
            "postal_code": "62626",
            "telephone_number": "217-854-2712"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "DEBORAH",
        "middle_name": "FAYE",
        "name_prefix": "Ms.",
        "credential": "LCPC LICENSED CLINIC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-03-19",
        "last_updated": "2024-03-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "IL",
            "license": "180.003816",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "DEBORAH",
            "last_name": "WALLACE",
            "middle_name": "FAYE",
            "prefix": "MS.",
            "credential": "LCPC MENTAL HEALTH T",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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• Professional Counselor in Carlinville, IL
• Providers in Carlinville, IL by specialty
• Professional Counselor in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.