Provider Demographics
NPI:1740367739
Name:WALLACE, EMMA B (LMFT)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:B
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 RANDALL PKWY
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2827
Mailing Address - Country:US
Mailing Address - Phone:910-332-8959
Mailing Address - Fax:910-332-8914
Practice Address - Street 1:4910 RANDALL PKWY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2827
Practice Address - Country:US
Practice Address - Phone:910-332-8959
Practice Address - Fax:910-332-8914
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC656106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist