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General NPI Number Information
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NPI Number | 1376783118
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Entity Type | Individual
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Provider Name | ELIZABETH DASHIELL WALLACE RN, LPC
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Gender | Female
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Dates
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Enumeration Date | 03/05/2009
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Last Update Date | 03/05/2009
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Provider Practice Location Address
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Address Line | 429 N CHURCH ST
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City | SPARTANBURG
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State | SC
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Zip | 29303-3612
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Country | US
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Telephone | 864-597-4371
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Fax | 864-597-4379
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Provider Business Mailing Address
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Address Line | 360 E KILLARNEY LK
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City | MOORE
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State | SC
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Zip | 29369-9489
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Country | US
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Telephone | 864-804-8381
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Fax | 864-804-8381
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4656
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License Number State | SC
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