Provider Demographics
NPI:1497866370
Name:WALLACE, INGRID (LPC, CRC)
Entity type:Individual
Prefix:MRS
First Name:INGRID
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 N MAYFAIR RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1403
Mailing Address - Country:US
Mailing Address - Phone:414-476-8183
Mailing Address - Fax:414-476-8465
Practice Address - Street 1:2525 N MAYFAIR RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1403
Practice Address - Country:US
Practice Address - Phone:414-476-8183
Practice Address - Fax:414-476-8465
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3065-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21280000Medicaid