Provider Demographics
NPI:1275698540
Name:WALLENS, PETER DAVID (MSW)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:DAVID
Last Name:WALLENS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3304 SELWYN FARMS LN APT 1
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-5006
Mailing Address - Country:US
Mailing Address - Phone:704-523-2100
Mailing Address - Fax:
Practice Address - Street 1:1801 E 5TH ST
Practice Address - Street 2:SUITE 212
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2379
Practice Address - Country:US
Practice Address - Phone:704-373-1000
Practice Address - Fax:704-373-1468
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0005731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical