Individual
JUANITA WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
570 SHACKELFORD RD, FLORISSANT, MO 63031-5457
(314) 583-0549
Mailing address
570 SHACKELFORD RD, ROAD, FLORISSANT, MO 63031-5457
(314) 583-0549
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
2002006418
MO
Other
Enumeration date
03/22/2007
Last updated
07/09/2007
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