Provider Demographics
NPI:1801136809
Name:WALLACE, MARY ETHERIDGE (LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ETHERIDGE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E. MAIN STREET SUITE 9
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-4452
Mailing Address - Country:US
Mailing Address - Phone:252-619-6629
Mailing Address - Fax:252-331-2499
Practice Address - Street 1:303 E. MAIN STREET SUITE 9
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-619-6629
Practice Address - Fax:252-331-2499
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005385101YP2500X
NC12837101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional