Provider Demographics
NPI:1629415070
Name:WALLACE, TAMIKA SHAVONE (LCSW- A)
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:SHAVONE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW- A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28312-5207
Mailing Address - Country:US
Mailing Address - Phone:910-584-3564
Mailing Address - Fax:
Practice Address - Street 1:511 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28312-5207
Practice Address - Country:US
Practice Address - Phone:910-584-3564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0094821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical