Provider Demographics
NPI:1841209392
Name:WALLACE, MONTE N (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MONTE
Middle Name:N
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 MALLARD ST
Mailing Address - Street 2:GMHC
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-4046
Mailing Address - Country:US
Mailing Address - Phone:864-241-1040
Mailing Address - Fax:864-241-1049
Practice Address - Street 1:124 MALLARD ST
Practice Address - Street 2:GMHC
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-4046
Practice Address - Country:US
Practice Address - Phone:864-241-1040
Practice Address - Fax:864-241-1049
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5525101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid
SC3333Medicare ID - Type Unspecified