Provider Demographics
NPI:1457754699
Name:WALLACE, DENISE
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:DEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:661 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-2339
Mailing Address - Country:US
Mailing Address - Phone:276-623-9245
Mailing Address - Fax:276-623-1183
Practice Address - Street 1:661 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-2339
Practice Address - Country:US
Practice Address - Phone:276-623-9245
Practice Address - Fax:276-623-1183
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904007863101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health