Sam Loc Wallace, L.P.C.

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

P0702007 Issued in AR

Practice address

1845 N Green Acres Rd
Fayetteville, AR 72703-2615

Phone

(479) 957-8546

NPI assigned

Mar 24, 2008

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Jan 3, 2024 through Jan 3, 2028

Medicare enrollment (NPD)

Not enrolled

State licenses

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.

• Synchronicity Group, LLC

  • Professional Counselor
  • Fayetteville, AR
  • NPI 1649548793
  Authorized official Same address or phone

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

{
    "created_epoch": "1206316800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1428451200000",
    "number": "1811169451",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1845 N GREEN ACRES RD",
            "city": "FAYETTEVILLE",
            "state": "AR",
            "postal_code": "727032615",
            "telephone_number": "479-957-8546"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1845 N GREEN ACRES RD",
            "city": "FAYETTEVILLE",
            "state": "AR",
            "postal_code": "727032615",
            "telephone_number": "479-957-8546"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "SAM",
        "middle_name": "LOC",
        "name_prefix": "Mr.",
        "credential": "L.P.C.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2008-03-24",
        "last_updated": "2015-04-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "AR",
            "license": "P0702007",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Dan L Wallace, LPC
• Logan Wallace
• Mykala R Wallace, LMSW
• Natalie Wallace
• Sadie Wallace
• Sarah M Wallace, MHPP
• Christina Walls, D.D.S.
• Walmart Inc. (Walmart Pharmacy 10-2997)
• Walmart Inc. (Walmart Pharmacy 10-0144)
• Walmart Inc. (Walmart Pharmacy 10-2745)

• Professional Counselor in Fayetteville, AR
• Providers in Fayetteville, AR by specialty
• Professional Counselor in Arkansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 8, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.