Provider Demographics
NPI:1942992938
Name:WALLACE, KATRINA LANET (LGSW)
Entity Type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:LANET
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14913 DENNINGTON DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3273
Mailing Address - Country:US
Mailing Address - Phone:301-351-0984
Mailing Address - Fax:
Practice Address - Street 1:2146 24TH PL NE # 2
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-1402
Practice Address - Country:US
Practice Address - Phone:202-774-5442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG500836461041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty