Healthcare Provider Details

I. General information

NPI: 1386508422
Provider Name (Legal Business Name): SUSAN WALLACE LPC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 CAROLINA PL STE 102-A
FORT MILL SC
29708-0014
US

IV. Provider business mailing address

PO BOX 175
FORT MILL SC
29716-0175
US

V. Phone/Fax

Practice location:
  • Phone: 803-402-3585
  • Fax:
Mailing address:
  • Phone: 803-402-3585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCOU10796
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: