Provider Demographics
NPI:1700898012
Name:WALLACE, GREGORY (LCSWC)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 CAMELBACK LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3810
Mailing Address - Country:US
Mailing Address - Phone:301-806-1892
Mailing Address - Fax:301-468-1862
Practice Address - Street 1:932 HUNGERFORD DR STE 18B
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-1751
Practice Address - Country:US
Practice Address - Phone:301-806-1892
Practice Address - Fax:301-468-1862
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12531104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD248050OtherKAISER
MD406695200Medicaid
MD64403601OtherBCBS OF MD
MD7383677OtherAETNA
MD724490000OtherMAGELLAN
DCA2840144OtherBCBS OF DC