Provider Demographics
NPI:1669937595
Name:WALLACE, TYSHAUNDRA RENEE (MED, LCASA, QP)
Entity type:Individual
Prefix:
First Name:TYSHAUNDRA
Middle Name:RENEE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MED, LCASA, QP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 DRUM RD APT 8
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-9062
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 PHILLIPS AVE
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7251
Practice Address - Country:US
Practice Address - Phone:336-854-2560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-25036101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)