Provider Demographics
NPI:1053501783
Name:WALLACE, ROGER A (MA)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-0127
Mailing Address - Country:US
Mailing Address - Phone:828-654-0111
Mailing Address - Fax:828-654-0111
Practice Address - Street 1:410 MILLS GAP RD.
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704
Practice Address - Country:US
Practice Address - Phone:828-654-0111
Practice Address - Fax:828-654-0111
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1179103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107178Medicaid