Provider Demographics
NPI:1154820868
Name:WALLACE, NICOLE JANEEN (LCMHC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JANEEN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 627
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27588-0627
Mailing Address - Country:US
Mailing Address - Phone:919-306-2579
Mailing Address - Fax:919-820-8571
Practice Address - Street 1:3041 BERKS WAY STE 102C
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-6777
Practice Address - Country:US
Practice Address - Phone:919-925-2274
Practice Address - Fax:919-820-8571
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13547101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty