Provider Demographics
NPI:1033378294
Name:WALLACE, DEAVEN MCGUIRE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:DEAVEN
Middle Name:MCGUIRE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21731 TIMBERLAKE RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-7400
Mailing Address - Country:US
Mailing Address - Phone:434-455-5033
Mailing Address - Fax:434-455-5034
Practice Address - Street 1:21731 TIMBERLAKE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-7400
Practice Address - Country:US
Practice Address - Phone:434-455-5033
Practice Address - Fax:434-455-5034
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004377101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional