Individual
KAITLYNN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1500 S AVE K, STATION 3, SHROC, PORTALES, NM 88130
(575) 562-2156
Mailing address
3319 E FOREST LAKE RD, ACAMPO, CA 95220-9573
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
—
—
390200000X
Student in an Organized Health Care Education/Training Program
—
CA
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
01/30/2019
Last updated
07/27/2021
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