Provider Demographics
NPI:1710521968
Name:WALLACE, LISA ANNE (MA, LPC, NCC, CCNHC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, LPC, NCC, CCNHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PALMETTO PARK BLVD APT 216
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7877
Mailing Address - Country:US
Mailing Address - Phone:803-707-4945
Mailing Address - Fax:
Practice Address - Street 1:418 BARR RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2363
Practice Address - Country:US
Practice Address - Phone:803-707-4945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7291101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health