Individual
DR. LEE TRAVIS WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHD
Contact information
Practice address
13740 HWY 183, #R-3, AUSTIN, TX 78750
(512) 331-1415
(512) 918-2325
Mailing address
13740 HWY 183, #R-3, AUSTIN, TX 78750
(512) 331-1415
(512) 918-2325
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
22772
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00A75L
BLUE CROSS BLUE SHIELD
—
Enumeration date
07/31/2006
Last updated
07/08/2007
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