Provider Demographics
NPI:1962091298
Name:WALLACE, MORGAN LINDSEY
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:LINDSEY
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 1:45397 ENGLEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-3518
Mailing Address - Country:US
Mailing Address - Phone:240-577-1383
Mailing Address - Fax:
Practice Address - Street 1:2601 WILLARD RD STE 103
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-3638
Practice Address - Country:US
Practice Address - Phone:855-444-9838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA1506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst