Provider Demographics
NPI:1609548197
Name:WALLACE, CYNTHIA C (MA, LCMHCS, NCC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, LCMHCS, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 LAMAR AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2436
Mailing Address - Country:US
Mailing Address - Phone:704-477-6044
Mailing Address - Fax:704-477-6044
Practice Address - Street 1:322 LAMAR AVE STE 209
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2436
Practice Address - Country:US
Practice Address - Phone:704-477-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCS6946101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional