Active NPI
Kathleen Michelle Wallace, LPC, NCC
- Mental Health Counselor
- Russellville, AR
National Provider Identifier
1508185307
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- P1507083
- Practice address
- 110 Skyline Dr
Russellville, AR 72801-3362 - Phone
- (479) 968-1298
- Fax
- (479) 890-5364
- NPI assigned
- May 19, 2010
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | P1507083 | AR | Primary |
Addresses
Primary practice location
110 Skyline Dr
Russellville, AR 72801-3362
Mailing address
110 Skyline Dr
Russellville, AR 72801-3362
Phone (479) 967-5570
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| P1507083 | AR | MD | Mental Health Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1274227200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1455494400000",
"number": "1508185307",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "110 SKYLINE DR",
"city": "RUSSELLVILLE",
"state": "AR",
"postal_code": "728013362",
"telephone_number": "479-967-5570",
"fax_number": "479-890-5364"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "110 SKYLINE DR",
"city": "RUSSELLVILLE",
"state": "AR",
"postal_code": "728013362",
"telephone_number": "479-968-1298",
"fax_number": "479-890-5364"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "KATHLEEN",
"middle_name": "MICHELLE",
"credential": "LPC, NCC",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2010-05-19",
"last_updated": "2016-02-15",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "AR",
"license": "P1507083",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Russellville, AR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 15, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.