DEDRA WALLACE – Professional Counselor, NPI 1063810877
Professional Counselor
Main info
Doctor Profile
Profile Insights
NPPES metrics only — not quality of care.
2,207 MENTAL HEALTH COUNSELOR in CO
Provider Addresses for DEDRA WALLACE
41 MONTEBELLO ROAD
SUITE 200
PUEBLO, CO 810041128
Phone: (719) 545-2746
Fax: (719) 545-4100
Type: Mailing
1302 CHINOOK LN
PUEBLO, CO 810011851
Phone: (719) 545-2746
Fax: (719) 545-4100
Type: Location
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
This can happen when there are no reportable CMS Open Payments records.
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2024-01-04
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Due date not assigned yet
CMS is tracking this Medicare enrollment for revalidation, but has not published a due date.
Enrollment records
1
Earliest due date
Not assigned (TBD)
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| I20240104004874 | I | Mental Health Counselor | CO | TBD |
What to do next
- No action required while the due date shows TBD.
- Check the CMS Revalidation Lookup Tool periodically — CMS updates the list about every 60 days.
- Do not submit a revalidation application in PECOS until CMS publishes a concrete due date.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 81004)
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Group practice members
| Name | Specialty | State |
|---|---|---|
| Nurse Practitioner | CO | |
| Clinical Social Worker | CO | |
| Mental Health Counselor | CO | |
| Clinical Social Worker | CO | |
| Clinical Social Worker | CO | |
| Mental Health Counselor | CO | |
| - | PA | |
| Clinical Psychologist | CO | |
| Clinical Psychologist | CO | |
| Mental Health Counselor | CO |
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