Provider Demographics
NPI:1104882612
Name:WALLACE, SYLVIA S (MED, LPC)
Entity type:Individual
Prefix:MRS
First Name:SYLVIA
Middle Name:S
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 JACOB TRL
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-8518
Mailing Address - Country:US
Mailing Address - Phone:704-736-9373
Mailing Address - Fax:
Practice Address - Street 1:315 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-2802
Practice Address - Country:US
Practice Address - Phone:704-736-9373
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2453101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC138UGOtherBLUE CROSS BLUE SHIELD