Active NPI
Lee Travis Wallace, PHD
- Clinical Psychologist
- Austin, TX
National Provider Identifier
1649286949
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 22772
- Practice address
- 13740 Hwy 183
#R-3
Austin, TX 78750 - Phone
- (512) 331-1415
- Fax
- (512) 918-2325
- NPI assigned
- Jul 31, 2006
- Last updated
- Jul 8, 2007
- Sex
- Male
- 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 |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 22772 | TX | Primary |
Addresses
Primary practice location
13740 Hwy 183
#R-3
Austin, TX 78750
Mailing address
13740 Hwy 183
#R-3
Austin, TX 78750
Phone (512) 331-1415
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00A75L | Other | BLUE CROSS BLUE SHIELD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in TX
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20050120000420 | TX | Practitioner - Clinical Psychologist | 5991754509 | Practice locations: Austin, TX |
Care Compare profile
Medicare Care Compare- Specialty
- Clinical Psychologist
- Education
- Other, 1980
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
9301 Evening Primrose Path
Austin, TX 78750-3631
Phone (512) 331-1415
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 22772 | TX | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1154304000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1649286949",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "13740 HWY 183",
"address_2": "#R-3",
"city": "AUSTIN",
"state": "TX",
"postal_code": "78750",
"telephone_number": "512-331-1415",
"fax_number": "512-918-2325"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "13740 HWY 183",
"address_2": "#R-3",
"city": "AUSTIN",
"state": "TX",
"postal_code": "78750",
"telephone_number": "512-331-1415",
"fax_number": "512-918-2325"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "LEE",
"middle_name": "TRAVIS",
"name_prefix": "Dr.",
"credential": "PHD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-07-31",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "TX",
"license": "22772",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "00A75L",
"state": null
}
],
"endpoints": [],
"other_names": []
}Other providers in Austin, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; 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.