Provider Demographics
NPI:1043612872
Name:WALLACE, AMBER LEIGH (LCSWC)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LEIGH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 HEALTHWAY DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-4470
Mailing Address - Country:US
Mailing Address - Phone:410-334-6961
Mailing Address - Fax:410-334-6362
Practice Address - Street 1:11120 SOMERSET AVE
Practice Address - Street 2:
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853-2970
Practice Address - Country:US
Practice Address - Phone:410-651-4200
Practice Address - Fax:410-651-4290
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20375104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR968OtherCAREFIRST
MD7840093OtherAETNA
MD609550004Medicaid
MD346646OtherTRICARE/MHN