Provider Demographics
NPI:1710855838
Name:WALLACE, MIATA QUINTAE (MS)
Entity type:Individual
Prefix:
First Name:MIATA
Middle Name:QUINTAE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 DUCK POND DR APT 301
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-3340
Mailing Address - Country:US
Mailing Address - Phone:757-910-9351
Mailing Address - Fax:
Practice Address - Street 1:1524 VOLVO PKWY STE B
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1516
Practice Address - Country:US
Practice Address - Phone:757-404-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-29
Last Update Date:2025-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor