Provider Demographics
NPI:1598358426
Name:WALLACE, SAMANDA JUSTINE
Entity Type:Individual
Prefix:
First Name:SAMANDA
Middle Name:JUSTINE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BOLDING ST
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-3505
Mailing Address - Country:US
Mailing Address - Phone:704-685-1733
Mailing Address - Fax:
Practice Address - Street 1:2675 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1478
Practice Address - Country:US
Practice Address - Phone:704-824-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician