Provider Demographics
NPI:1649286949
Name:WALLACE, LEE TRAVIS (PHD)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:TRAVIS
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13740 HWY 183
Mailing Address - Street 2:#R-3
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750
Mailing Address - Country:US
Mailing Address - Phone:512-331-1415
Mailing Address - Fax:512-918-2325
Practice Address - Street 1:13740 HWY 183
Practice Address - Street 2:#R-3
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750
Practice Address - Country:US
Practice Address - Phone:512-331-1415
Practice Address - Fax:512-918-2325
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22772103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A75LOtherBLUE CROSS BLUE SHIELD
00A75LMedicare ID - Type Unspecified