Provider Demographics
NPI:1376783118
Name:WALLACE, ELIZABETH DASHIELL (RN, LPC)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:DASHIELL
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 E KILLARNEY LK
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:SC
Mailing Address - Zip Code:29369-9489
Mailing Address - Country:US
Mailing Address - Phone:864-804-8381
Mailing Address - Fax:864-804-8381
Practice Address - Street 1:429 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3612
Practice Address - Country:US
Practice Address - Phone:864-597-4371
Practice Address - Fax:864-597-4379
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-05
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4656101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional