Mary Etheridge Wallace, LPC
Counselor, Professional in Elizabeth City, NC. Individual provider (NPI-1).
NPI number1801136809
StatusActive
Last updated in NPPESSep 6, 2018
Details
- NPI
- 1801136809
- Entity type
- Individual (NPI-1)
- Name
- Mary Etheridge Wallace
- Credential
- LPC
- Sex
- Female
- Sole proprietor
- No
- Enumeration date
- Feb 27, 2013
- Last updated
- Sep 6, 2018
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 101YP2500X | Counselor, Professional | 12837 | NC | Yes |
| 101YP2500X | Counselor, Professional | 0701005385 | VA |
Practice location
303 E. Main Street Suite 9Elizabeth City, NC 27909
Phone 252-619-6629 · Fax 252-331-2499
Mailing address
303 E. Main Street Suite 9Elizabeth City, NC 27909-4452
Phone 252-619-6629 · Fax 252-331-2499
Other practice locations
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