Provider Demographics
NPI:1871155242
Name:WALLACE, HENRY HUGH
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:HUGH
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6236 RHONES QUARTER RD LOT 13
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-6479
Mailing Address - Country:US
Mailing Address - Phone:903-952-9869
Mailing Address - Fax:
Practice Address - Street 1:6236 RHONES QUARTER RD LOT 13
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-6479
Practice Address - Country:US
Practice Address - Phone:903-952-9869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201549106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist