Provider Demographics
NPI:1467028159
Name:PEAKE, WALLACE T JR (MSW, LCSWA)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:T
Last Name:PEAKE
Suffix:JR
Gender:M
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4614 WILGROVE MINT HILL RD # 1
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-3500
Mailing Address - Country:US
Mailing Address - Phone:980-231-1937
Mailing Address - Fax:
Practice Address - Street 1:1935 J N PEASE PL STE 104
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4541
Practice Address - Country:US
Practice Address - Phone:980-288-5486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0162441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical