Provider Demographics
NPI:1871238725
Name:WALLACE, JULIE ANNE (LCMHCA)
Entity Type:Individual
Prefix:MISS
First Name:JULIE
Middle Name:ANNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:MRS
Other - First Name:JULIE
Other - Middle Name:ANNE
Other - Last Name:MOLISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCMHCA
Mailing Address - Street 1:241 CHELTENHAM DR
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-6663
Mailing Address - Country:US
Mailing Address - Phone:803-522-2247
Mailing Address - Fax:
Practice Address - Street 1:3820 MERTON DR STE 218
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6609
Practice Address - Country:US
Practice Address - Phone:919-781-8370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCTBD101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional