Provider Demographics
NPI:1730941899
Name:WALLACE, CARLEE D P (LMFT)
Entity type:Individual
Prefix:
First Name:CARLEE
Middle Name:D P
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 W LITTLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-6543
Mailing Address - Country:US
Mailing Address - Phone:208-690-1270
Mailing Address - Fax:
Practice Address - Street 1:1406 W LITTLE CREEK DR
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-6543
Practice Address - Country:US
Practice Address - Phone:208-690-1270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-24
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist