Provider Demographics
NPI:1992082416
Name:WALLACE, SENETRA (LCSW)
Entity type:Individual
Prefix:MS
First Name:SENETRA
Middle Name:
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:PO BOX 52271
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27717-2271
Mailing Address - Country:US
Mailing Address - Phone:919-247-9534
Mailing Address - Fax:919-467-4219
Practice Address - Street 1:4909 WATERS EDGE DR
Practice Address - Street 2:107
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-2462
Practice Address - Country:US
Practice Address - Phone:919-247-9534
Practice Address - Fax:919-467-4219
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-11
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0089191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ47584D882Medicare PIN