Provider Demographics
NPI:1962950725
Name:WALLACE, BRITTNEY (PSYD, ABPP)
Entity type:Individual
Prefix:
First Name:BRITTNEY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PSYD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MLG PSYCH
Mailing Address - Street 2:BLDG 327
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547
Mailing Address - Country:US
Mailing Address - Phone:109-451-6628
Mailing Address - Fax:
Practice Address - Street 1:MLG PSYCH
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547
Practice Address - Country:US
Practice Address - Phone:109-451-6628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
VA0810006150103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist