Provider Demographics
NPI:1235960774
Name:WALLACE, HEAVEN CATHERINE
Entity type:Individual
Prefix:
First Name:HEAVEN
Middle Name:CATHERINE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 N POST OAK RD STE 145
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-3923
Mailing Address - Country:US
Mailing Address - Phone:713-364-6275
Mailing Address - Fax:
Practice Address - Street 1:701 N POST OAK RD STE 145
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-3923
Practice Address - Country:US
Practice Address - Phone:713-364-6275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110854104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker