Provider Demographics
NPI:1770169955
Name:WALLACE, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 HARCOURT RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2073
Mailing Address - Country:US
Mailing Address - Phone:317-338-4896
Mailing Address - Fax:317-338-4890
Practice Address - Street 1:8401 HARCOURT RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2073
Practice Address - Country:US
Practice Address - Phone:317-338-4896
Practice Address - Fax:317-338-4890
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2025-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88001290A101YM0800X
SC10594101YM0800X
IN39004417A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health