Provider Demographics
NPI:1912364787
Name:WALLACE, BONITA LUCILLE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:LUCILLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 PHARR RD NE
Mailing Address - Street 2:SUITE 605
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-3428
Mailing Address - Country:US
Mailing Address - Phone:404-664-6398
Mailing Address - Fax:678-705-2758
Practice Address - Street 1:550 PHARR RD NE
Practice Address - Street 2:SUITE 605
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-3428
Practice Address - Country:US
Practice Address - Phone:404-664-6398
Practice Address - Fax:678-705-2758
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1823101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional