Healthcare Provider Details

I. General information

NPI: 1962091298
Provider Name (Legal Business Name): MORGAN LINDSEY WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 WILLARD RD STE 103
RICHMOND VA
23294-3638
US

IV. Provider business mailing address

45397 ENGLEWOOD WAY
CALIFORNIA MD
20619-3518
US

V. Phone/Fax

Practice location:
  • Phone: 855-444-9838
  • Fax:
Mailing address:
  • Phone: 240-577-1383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA1506
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: