Provider Demographics
NPI:1811717937
Name:WALLACE SCHUTZ, SARA REGINA (LAPC)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:REGINA
Last Name:WALLACE SCHUTZ
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 TWELVE OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-1908
Mailing Address - Country:US
Mailing Address - Phone:615-403-5910
Mailing Address - Fax:
Practice Address - Street 1:1711 MERIWEATHER DR
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7788
Practice Address - Country:US
Practice Address - Phone:615-403-5910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009257101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health