Provider Demographics
NPI:1922702000
Name:WALLACE, REBECCA ELIZABETH (LPES)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ELIZABETH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10070 DORCHESTER RD UNIT 50017
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-2507
Mailing Address - Country:US
Mailing Address - Phone:843-376-3112
Mailing Address - Fax:843-594-0110
Practice Address - Street 1:1815 BACONS BRIDGE
Practice Address - Street 2:B12
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-2507
Practice Address - Country:US
Practice Address - Phone:843-376-3112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4797103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool