Provider Demographics
NPI:1356927388
Name:WALLACE, KATHERINE JOAN (LMHC)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:JOAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10655 W 650 S
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-8476
Mailing Address - Country:US
Mailing Address - Phone:317-775-9075
Mailing Address - Fax:
Practice Address - Street 1:719 5TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-6306
Practice Address - Country:US
Practice Address - Phone:812-799-3530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-21
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88001289A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN39004527AOtherINDIANA BEHAVIORAL HEALTH LICENSING BOARD