Provider Demographics
NPI:1811195605
Name:WALLACE, PEGGY S (LCSW)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:S
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 GRAPPENHALL DR
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-2215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 CORNERSTONE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-8481
Practice Address - Country:US
Practice Address - Phone:919-463-8426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0044151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical