Provider Demographics
NPI:1184597999
Name:WALLACE, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
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 1:2330 DULLES STATION BLVD APT 2229
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-6196
Mailing Address - Country:US
Mailing Address - Phone:972-400-2932
Mailing Address - Fax:
Practice Address - Street 1:4530 WALNEY RD STE 105
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-2285
Practice Address - Country:US
Practice Address - Phone:619-818-1807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician