Individual
MRS. CONNIE LEE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LPCC-S, CTT
Contact information
Practice address
547 1/2 S JAMES ST, STE. A, DOVER, OH 44622-2137
(330) 343-7400
(330) 343-7414
Mailing address
PO BOX 534, NEW PHILADELPHIA, OH 44663-0534
(330) 343-7400
(330) 343-7414
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
E0001636-SUPV
OH
101YP2500X
Professional Counselor
E0001636-SUPV
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
741212
—
OH
Enumeration date
07/26/2006
Last updated
02/16/2016
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