Provider Demographics
NPI:1134253396
Name:WALLACE, MARY BETH (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2461 HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:AR
Mailing Address - Zip Code:72432-9479
Mailing Address - Country:US
Mailing Address - Phone:870-578-2763
Mailing Address - Fax:
Practice Address - Street 1:2461 HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:AR
Practice Address - Zip Code:72432-9479
Practice Address - Country:US
Practice Address - Phone:870-578-2763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1978235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148690721Medicaid