Provider Demographics
NPI:1316810385
Name:WALLACE, CALVIN RAINFORD
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:RAINFORD
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 LAKE PARK DR APT 103
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-7001
Mailing Address - Country:US
Mailing Address - Phone:240-535-3066
Mailing Address - Fax:
Practice Address - Street 1:6500 LAKE PARK DR APT 103
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-7001
Practice Address - Country:US
Practice Address - Phone:240-535-3066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-25
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC15390101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty