Provider Demographics
NPI:1679821201
Name:WALLACE, ALISON QUINN (LPC)
Entity Type:Individual
Prefix:
First Name:ALISON
Middle Name:QUINN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 W ALTMAN ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5212
Mailing Address - Country:US
Mailing Address - Phone:912-764-2402
Mailing Address - Fax:912-764-5561
Practice Address - Street 1:3 W ALTMAN ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5212
Practice Address - Country:US
Practice Address - Phone:912-764-2402
Practice Address - Fax:912-764-5561
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008383101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional