Provider Demographics
NPI:1639870702
Name:WALLACE, ANAH (LCSW-A)
Entity Type:Individual
Prefix:
First Name:ANAH
Middle Name:
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 1:2812 CROSS POINT CIR APT 37
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-4425
Mailing Address - Country:US
Mailing Address - Phone:980-349-6663
Mailing Address - Fax:
Practice Address - Street 1:9723 NORTHEAST PKWY STE 500
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-9718
Practice Address - Country:US
Practice Address - Phone:980-349-6663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0186411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical