Connie Lee Wallace, LPCC-S, CTT

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

E0001636-SUPV Issued in OH

Practice address

547 1/2 S James St
Ste. a
Dover, OH 44622-2137

Phone

(330) 343-7400

Fax

(330) 343-7414

NPI assigned

Jul 26, 2006

Last updated

Feb 16, 2016By the provider in NPPES

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in OH

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Mental Health Counselor

Education

Other, 1986

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Guiding Grace Counseling LLC

  • Mental Health Counselor
  • Dover, OH
  • NPI 1639325871
  Medicare reassignment NPD Authorized official

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

{
    "created_epoch": "1153872000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1455580800000",
    "number": "1386668200",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 534",
            "city": "NEW PHILADELPHIA",
            "state": "OH",
            "postal_code": "446630534",
            "telephone_number": "330-343-7400",
            "fax_number": "330-343-7414"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "547 1/2 S JAMES ST",
            "address_2": "STE. A",
            "city": "DOVER",
            "state": "OH",
            "postal_code": "446222137",
            "telephone_number": "330-343-7400",
            "fax_number": "330-343-7414"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "CONNIE",
        "middle_name": "LEE",
        "name_prefix": "Mrs.",
        "credential": "LPCC-S, CTT",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2006-07-26",
        "last_updated": "2016-02-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "OH",
            "license": "E0001636-SUPV",
            "primary": true
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "OH",
            "license": "E0001636-SUPV",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "741212",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Upmc Twin City
• John D Uvena, DC
• Keith Chapin Vanepps, M.D
• Gina Marie Vitale-Amos, NP-C
• Wakefield Dental of Dover LLC
• Jamie Renee' Wallace, RN, BSN
• Wendi Sue Waller, RN
• Barbara J Wallis, LPCC-SUPV
• Dereck Walton
• Robert L Ward, CRNA

• Mental Health Counselor in Dover, OH
• Providers in Dover, OH by specialty
• Mental Health Counselor in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 16, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.