Individual
MARY LOUISE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MA, CCC-SLP
Contact information
Practice address
6672 GUNPARK DR, SUITE 101 C, BOULDER, CO 80301-3387
(303) 530-9191
Mailing address
6672 GUNPARK DR, SUITE 101 C, BOULDER, CO 80301-3387
(303) 530-9191
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
00198044
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
07198047
—
CO
Enumeration date
09/06/2006
Last updated
07/09/2007
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