Healthcare Provider Details

I. General information

NPI: 1700898012
Provider Name (Legal Business Name): GREGORY WALLACE LCSWC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 HUNGERFORD DR STE 18B
ROCKVILLE MD
20850-1751
US

IV. Provider business mailing address

6005 CAMELBACK LN
COLUMBIA MD
21045-3810
US

V. Phone/Fax

Practice location:
  • Phone: 301-806-1892
  • Fax: 301-468-1862
Mailing address:
  • Phone: 301-806-1892
  • Fax: 301-468-1862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12531
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12531
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: