Provider Demographics
NPI:1649311804
Name:WALLACE-BORDERS, REBECCA ASHLEY (LCSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ASHLEY
Last Name:WALLACE-BORDERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:W
Other - Last Name:BORDERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:10299 WOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-4419
Mailing Address - Country:US
Mailing Address - Phone:804-727-8500
Mailing Address - Fax:804-727-8580
Practice Address - Street 1:17320 NEW KENT HWY
Practice Address - Street 2:
Practice Address - City:BARHAMSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23011-2353
Practice Address - Country:US
Practice Address - Phone:804-652-1245
Practice Address - Fax:804-652-1244
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040053231041C0700X
MO20020118981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical