Healthcare Provider Details

I. General information

NPI: 1558226621
Provider Name (Legal Business Name): SELINA SAMANTHA WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2244 EXECUTIVE DR
HAMPTON VA
23666-2430
US

IV. Provider business mailing address

261 BELMONT CIR
YORKTOWN VA
23693-4451
US

V. Phone/Fax

Practice location:
  • Phone: 757-827-1001
  • Fax:
Mailing address:
  • Phone: 803-757-8252
  • Fax: 803-757-8252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701015709
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: