Provider Demographics
NPI:1255053609
Name:WALLACE, CRISTEN (CSC-AD)
Entity type:Individual
Prefix:
First Name:CRISTEN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CSC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 N CHARLES ST STE 101B
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-4032
Mailing Address - Country:US
Mailing Address - Phone:443-845-4639
Mailing Address - Fax:
Practice Address - Street 1:222 N CHARLES ST STE 101B
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4032
Practice Address - Country:US
Practice Address - Phone:443-845-4639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC2995101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)