Provider Demographics
NPI:1588900989
Name:WALLACE, SHELVEY JEAN (LCSW)
Entity type:Individual
Prefix:
First Name:SHELVEY
Middle Name:JEAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5306 NC HIGHWAY 55 STE 105
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-7812
Mailing Address - Country:US
Mailing Address - Phone:919-457-1517
Mailing Address - Fax:919-363-7697
Practice Address - Street 1:5306 NC HIGHWAY 55 STE 105
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-7812
Practice Address - Country:US
Practice Address - Phone:919-457-1517
Practice Address - Fax:919-363-7697
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-21629101YA0400X
NCC0100421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)