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DEDRA WALLACE
NPI 1063810877
Counselor - Professional in Pueblo, CO

Active since December 10, 2014PECOS EnrolledAccepts Medicare Assignment
1302 CHINOOK LN, PUEBLO, CO 81001(719) 545-2746(719) 545-4100 Get Directions Write a Review

NPPES record last updated: October 19, 2016. Verified against the NPPES registry weekly; last sync: August 09, 2026.

About Dedra Wallace NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

DEDRA WALLACE (NPI 1063810877) is an individual professional provider in Pueblo, Colorado, licensed in Colorado (LPC.0013214) and active in the NPI registry since December 2014. She is enrolled in Medicare PECOS and is a graduate of Other (2014).

NPPES Registry Identity

NPI1063810877
Entity TypeIndividualFemale
Primary Taxonomy101YP2500X
Provider Legal NameDEDRA WALLACE
Location Address1302 CHINOOK LNPueblo, CO 81001-1851
Mailing Address41 Montebello Road, Suite 200Pueblo, CO 81004-1128 · (719) 545-2746 · Fax (719) 545-4100
Phone(719) 545-2746
Fax(719) 545-4100
Sole ProprietorNo
Medical School CMSOtherGraduated 2014
Enumeration DateDecember 10, 2014
Last NPPES UpdateOctober 19, 2016
✔ NPI 1063810877 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyCounselor · ProfessionalBehavioral Health & Social Service Providers
Taxonomy Code101YP2500X
License✔ Licensed in CO · LPC.0013214
1302 CHINOOK LN, Pueblo, CO 81001
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Medicare Participation & PECOS CMS

Medicare enrollment, assignment, and ordering and referring status from the CMS PECOS system.

Medicare Enrollment Status

✔

Enrolled in Medicare and accepts Medicare assignment

Dedra Wallace is registered in PECOS and agrees to accept the Medicare-approved amount as full payment. Medicare patients are not billed beyond the standard deductible and coinsurance.

PECOS PAC ID4486005345
PECOS Enrollment IDI20240104004874
Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment– Home Health Agency– Power Mobility DevicesPer the CMS Ordering and Referring file. Eligibility means Medicare pays claims that this provider orders or refers for these categories.

Other Providers at the Same Location NPPES 20

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

JAYCOB GONZALES-CORDOVA
Counselor
1302 CHINOOK LN
PUEBLO, CO 81001
Pueblo County (719) 545-2746
HEALTH SOLUTIONS
Clinic/Center (Mental Health (Including Community Mental Health Center))
1302 CHINOOK LN
PUEBLO, CO 81001
Pueblo County (719) 545-2746
RAQUEL ARAGON
Counselor
1302 CHINOOK LN
PUEBLO, CO 81001
Pueblo County (719) 545-2746
SAMANTHA KELLER
Registered Nurse
1302 CHINOOK LN
PUEBLO, CO 81001
Pueblo County (719) 545-2746
CHRISTY BURNETT
Counselor
1302 CHINOOK LN
PUEBLO, CO 81001
Pueblo County (719) 545-2746
RICCO NANCY JULIA LCPC
Counselor (Professional)
1302 CHINOOK LN
PUEBLO, CO 81001
Pueblo County (719) 545-2746
KIRSTEN MONTGOMERY
Counselor (Mental Health)
1302 CHINOOK LN
PUEBLO, CO 81001
Pueblo County (719) 545-2746
VANESSA BENAVIDEZ CST, FA
Specialist/Technologist, Other (Surgical Technologist)
1302 CHINOOK LN
PUEBLO, CO 81001
Pueblo County (719) 545-2746

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Dedra Wallace's NPI number?

The NPI number for Dedra Wallace is 1063810877. It was assigned to this individual provider in the NPPES registry on December 10, 2014.

Where is Dedra Wallace located?

Dedra Wallace practices at 1302 Chinook Ln, Pueblo, CO 81001. The listed phone number is (719) 545-2746.

What is Dedra Wallace's specialty?

The primary specialty registered for this NPI is Counselor, specializing in Professional, with taxonomy code 101YP2500X.

Is Dedra Wallace enrolled in Medicare?

Yes. Dedra Wallace is registered in the Medicare PECOS system and accepts Medicare assignment, which means accepting the Medicare-approved amount as payment in full for covered services.

When was this NPI record last updated?

The NPPES record for Dedra Wallace was last updated on October 19, 2016. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 9 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.