Provider Demographics
NPI:1821874389
Name:WALLACE, LULA (CAC-AD)
Entity Type:Individual
Prefix:
First Name:LULA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4108 FALLSTAFF RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-1411
Mailing Address - Country:US
Mailing Address - Phone:443-660-9929
Mailing Address - Fax:
Practice Address - Street 1:821 N EUTAW ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4648
Practice Address - Country:US
Practice Address - Phone:410-225-9185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDACO333101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)