Individual
MR. TERRY EUGENE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CADC
Contact information
Practice address
104 NE AVENUE A, IDABEL, OK 74745
(580) 286-3301
Mailing address
HC 73 BOX 348, HAWORTH, OK 74740-9515
(580) 245-2990
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
558
OK
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
71
OK
101YA0400X
Addiction (Substance Use Disorder) Counselor
9591601399
OK
Other
Enumeration date
05/11/2007
Last updated
07/08/2007
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