Provider Demographics
NPI:1861723264
Name:RUE-WALLACE, TERESA GALE (BA,MS)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:GALE
Last Name:RUE-WALLACE
Suffix:
Gender:F
Credentials:BA,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34668 E COUNTY ROAD 1650
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:OK
Mailing Address - Zip Code:73098-9173
Mailing Address - Country:US
Mailing Address - Phone:405-306-8511
Mailing Address - Fax:405-665-6396
Practice Address - Street 1:34668 E COUNTY ROAD 1650
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:OK
Practice Address - Zip Code:73098-9173
Practice Address - Country:US
Practice Address - Phone:405-306-8511
Practice Address - Fax:405-665-6396
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health