Individual
DR. AMANDA JO WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PSY.D.
Contact information
Practice address
1500 N WESTWOOD BLVD, POPLAR BLUFF, MO 63901-3318
(573) 778-4122
Mailing address
1500 N WESTWOOD BLVD, POPLAR BLUFF, MO 63901-3318
(573) 778-4122
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
2009031094
MO
103TF0200X
Forensic Psychologist
2009031094
MO
Other
Enumeration date
10/31/2014
Last updated
10/31/2014
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