Provider Demographics
NPI:1023723285
Name:WALLACE, KARYN DE'NEAN
Entity type:Individual
Prefix:MRS
First Name:KARYN
Middle Name:DE'NEAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20505 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-8819
Mailing Address - Country:US
Mailing Address - Phone:704-975-9291
Mailing Address - Fax:
Practice Address - Street 1:442 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-8222
Practice Address - Country:US
Practice Address - Phone:704-975-9291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18495101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health