Provider Demographics
NPI:1720370570
Name:WALLACE, ALICIA ANGELA (LCPC)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:ANGELA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3718 MILFORD MILL RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-3718
Mailing Address - Country:US
Mailing Address - Phone:443-801-8732
Mailing Address - Fax:
Practice Address - Street 1:3718 MILFORD MILL RD
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-3718
Practice Address - Country:US
Practice Address - Phone:443-801-8732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2999101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional