Provider Demographics
NPI:1730770207
Name:WALLACE, GWENDOLYN DEANE (MS-CF,SLP)
Entity type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:DEANE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS-CF,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1019
Mailing Address - Country:US
Mailing Address - Phone:607-270-6968
Mailing Address - Fax:601-758-0982
Practice Address - Street 1:4805 W 4TH ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1019
Practice Address - Country:US
Practice Address - Phone:601-270-6968
Practice Address - Fax:601-758-0982
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS-4735235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty