Provider Demographics
NPI:1225854243
Name:WALLACE, ASHLEY H
Entity type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:H
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10745 MISTY MEADOWS CT
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-6162
Mailing Address - Country:US
Mailing Address - Phone:404-886-7177
Mailing Address - Fax:
Practice Address - Street 1:10745 MISTY MEADOWS CT
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-6162
Practice Address - Country:US
Practice Address - Phone:404-886-7177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC009108101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty