Most Relevant Information
Provider Data
| NPI Number: | 1003321720 |
| Provider Name: | DARRE'LL J WALLACE |
| Entity Type: | Individual |
| Taxonomy Code: | 101YM0800X |
| Specialty: | Counselor |
| License Number: |
Most Important Dates
| Enumeration Date: | 12/04/2017 |
| Last Updated: | 12/04/2017 |
Provider Practice Location
1711 MARSHALL ST
SHREVEPORT
LA
711014139
Practice Location Phone/Fax
| Phone: | 3182269944 |
| Fax: | 3182269942 |
Provider Mailing Location
1711 MARSHALL ST
SHREVEPORT
LA
711014139
Provider Mailing Phone/Fax
| Phone: | 3182269944 |
| Fax: | 3182269942 |