Provider Demographics
NPI:1275318420
Name:WALLENBECK, LUKE ALLAN
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:ALLAN
Last Name:WALLENBECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2449 BERTIE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1730
Mailing Address - Country:US
Mailing Address - Phone:919-889-2666
Mailing Address - Fax:
Practice Address - Street 1:353 E SIX FORKS RD STE 230
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7882
Practice Address - Country:US
Practice Address - Phone:919-263-4421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19008101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor