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General NPI Number Information
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NPI Number | 1215294152
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Entity Type | Individual
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Provider Name | FELICIA LEE WALLACE LCSW
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Gender | Female
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Dates
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Enumeration Date | 04/17/2012
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Last Update Date | 04/08/2025
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Provider Practice Location Address
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Address Line | 100 EMANCIPATION DR BLDG 71
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City | HAMPTON
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State | VA
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Zip | 23667-0001
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Country | US
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Telephone | 757-722-9961
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Fax |
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Provider Business Mailing Address
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Address Line | 100 EMANCIPATION DR BLDG 71
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City | HAMPTON
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State | VA
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Zip | 23667-0001
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Country | US
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Telephone | 757-722-9961
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149028883
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0904018214
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License Number State | VA
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