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General NPI Number Information
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NPI Number | 1386508422
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Entity Type | Individual
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Provider Name | MS. SUSAN WALLACE
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Gender | Female
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Dates
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Enumeration Date | 12/12/2025
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Last Update Date | 12/12/2025
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Provider Practice Location Address
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Address Line | 122 CLEBOURNE ST
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City | FORT MILL
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State | SC
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Zip | 29715-1753
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Country | US
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Telephone | 704-931-1010
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Fax |
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Provider Business Mailing Address
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Address Line | 335 KENNEBEL PL
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City | FORT MILL
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State | SC
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Zip | 29715-4101
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Country | US
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Telephone | 980-613-1443
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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 | 171400000X
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Taxonomy Name | Health & Wellness Coach
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License Number |
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License Number State | SC
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