Basic Information
| Provider Information | |||||||||
| NPI: | 1952604183 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 ADAMS PARK CT | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319093525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065070442 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2100 COMER AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319048725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063230174 | ||||||||
| FaxNumber: | 7062563264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2010 | ||||||||
| LastUpdateDate: | 12/09/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC004754 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.