Provider Demographics
NPI:1376897694
Name:WALLACE, ABBY (LAPC)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 FANT DR
Mailing Address - Street 2:
Mailing Address - City:FORT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-3307
Mailing Address - Country:US
Mailing Address - Phone:706-806-1169
Mailing Address - Fax:706-806-1186
Practice Address - Street 1:1875 FANT DR
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3307
Practice Address - Country:US
Practice Address - Phone:706-806-1169
Practice Address - Fax:706-806-1186
Is Sole Proprietor?:No
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC003548101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional