Provider Demographics
NPI:1891224283
Name:WALDROP, WALLACE JERRY JR (LMFT)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:JERRY
Last Name:WALDROP
Suffix:JR
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2917 MILLWOOD AVE BLDG B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-1334
Mailing Address - Country:US
Mailing Address - Phone:803-814-6218
Mailing Address - Fax:855-490-9560
Practice Address - Street 1:2917 MILLWOOD AVE BLDG B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-1334
Practice Address - Country:US
Practice Address - Phone:803-814-6218
Practice Address - Fax:855-490-9560
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1746106H00000X
SC6995106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist