Provider Demographics
NPI:1518423045
Name:WALLACE, FORMECIA (MS, MA, LCAS-A)
Entity Type:Individual
Prefix:
First Name:FORMECIA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, MA, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 WYNN RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27892-8844
Mailing Address - Country:US
Mailing Address - Phone:252-864-6835
Mailing Address - Fax:
Practice Address - Street 1:618 E BOULEVARD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-2736
Practice Address - Country:US
Practice Address - Phone:252-792-0659
Practice Address - Fax:252-792-0660
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25169101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)