Provider Demographics
NPI:1295438893
Name:WALLACE, KRYSTAL JACQUELYN (MS MA BC)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:JACQUELYN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS MA BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 ALLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40210-2004
Mailing Address - Country:US
Mailing Address - Phone:708-699-5619
Mailing Address - Fax:
Practice Address - Street 1:618 E MARKET ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-2914
Practice Address - Country:US
Practice Address - Phone:502-579-1278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty