Provider Demographics
NPI:1902902059
Name:WALLACE, GORDON STEVEN (LCPC / LAC)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:STEVEN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LCPC / LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 15TH ST W
Mailing Address - Street 2:P.O. BOX 50090
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-4155
Mailing Address - Country:US
Mailing Address - Phone:406-256-1434
Mailing Address - Fax:
Practice Address - Street 1:1250 15TH ST W
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-4155
Practice Address - Country:US
Practice Address - Phone:406-256-1434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT970101YA0400X
MT942-LCPC101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional