Provider Demographics
NPI:1902938558
Name:WALLACE, TRIPHINIA M (PSY)
Entity type:Individual
Prefix:
First Name:TRIPHINIA
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:
Credentials:PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4062 PEACHTREE RD NE # 190A
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3021
Mailing Address - Country:US
Mailing Address - Phone:404-317-2283
Mailing Address - Fax:404-393-6692
Practice Address - Street 1:4062 PEACHTREE RD NE # 190A
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-3021
Practice Address - Country:US
Practice Address - Phone:404-317-2283
Practice Address - Fax:404-393-6692
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2025-03-14
Deactivation Date:2022-08-17
Deactivation Code:
Reactivation Date:2022-11-15
Provider Licenses
StateLicense IDTaxonomies
GAGA003723103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist