Healthcare Provider Details

I. General information

NPI: 1558440263
Provider Name (Legal Business Name): H. MAC WALLACE LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

923 CHADWICK SHORES DR
SNEADS FERRY NC
28460-9213
US

IV. Provider business mailing address

923 CHADWICK SHORES DR
SNEADS FERRY NC
28460-9213
US

V. Phone/Fax

Practice location:
  • Phone: 910-470-0346
  • Fax: 910-332-8914
Mailing address:
  • Phone: 910-470-0346
  • Fax: 910-332-8914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number363
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: