Provider Demographics
NPI:1245345750
Name:WALLACE, MEG (LPC)
Entity type:Individual
Prefix:
First Name:MEG
Middle Name:
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 1:12807 KETTERING DR
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2446
Mailing Address - Country:US
Mailing Address - Phone:703-435-4325
Mailing Address - Fax:703-435-4325
Practice Address - Street 1:297 HERNDON PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4474
Practice Address - Country:US
Practice Address - Phone:703-435-4325
Practice Address - Fax:703-435-4325
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1808101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0600001OtherCARE 1ST ID
VA200642OtherANTHEM ID