Provider Demographics
NPI:1558384164
Name:WALLACE, DONYA DEMESHA (LPC)
Entity type:Individual
Prefix:
First Name:DONYA
Middle Name:DEMESHA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:992 JASMINE LN
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-8599
Mailing Address - Country:US
Mailing Address - Phone:843-773-9649
Mailing Address - Fax:
Practice Address - Street 1:201 SHORT ST
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-3926
Practice Address - Country:US
Practice Address - Phone:842-354-7324
Practice Address - Fax:843-354-6461
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4697101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCWP8972Medicaid