Individual
MADISON WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LPCC
Contact information
Practice address
450 OLD VINE ST STE 305, LEXINGTON, KY 40507-1544
(859) 667-4301
Mailing address
1351 NEWTOWN PIKE, BUILDING 5, LEXINGTON, KY 40511-1275
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
260537
KY
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1790731081
—
KY
Enumeration date
11/10/2016
Last updated
11/19/2024
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