MEDICARE: JOYCE W WALLACE LCSW, LISW-CP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	C010071	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3000641104	OTHER	SC	WORKER'S COMP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942432851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOYCE W WALLACE LCSW, LISW-CP

Provider Business Mailing Address
First Line	:	3211 MALLARD HILL DR
Second Line	:	APT 203
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-2069
Country	:	US
Telephone Number	:	803-979-5639
Fax Number	:

Provider Business Practice Location Address
First Line	:	3211 MALLARD HILL DR
Second Line	:	APT 203
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-2069
Country	:	US
Telephone Number	:	803-979-5639
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2009
Last Update Date	:	02/17/2017

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