Healthcare Provider Details

I. General information

NPI: 1669937595
Provider Name (Legal Business Name): TYSHAUNDRA RENEE WALLACE M.ED, LCASA, QP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 PHILLIPS AVE
HIGH POINT NC
27262-7251
US

IV. Provider business mailing address

438 DRUM RD APT 8
REIDSVILLE NC
27320-9062
US

V. Phone/Fax

Practice location:
  • Phone: 336-854-2560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCAS-25036
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: