Basic Information
| Provider Information | |||||||||
| NPI: | 1013164490 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | TEKISHA | ||||||||
| MiddleName: | LEVONNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251831 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1236 WEST INNES ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281444064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046333616 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2008 | ||||||||
| LastUpdateDate: | 10/07/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 8091 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.