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General NPI Number Information
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NPI Number | 1548052178
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Entity Type | Individual
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Provider Name | CHRISTOPHER JAMES WALLACE LCPC-C, CADC
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Gender | Male
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Dates
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Enumeration Date | 05/20/2025
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Last Update Date | 07/09/2025
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Provider Practice Location Address
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Address Line | 420 CUMBERLAND AVE
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City | PORTLAND
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State | ME
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Zip | 04101-2823
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Country | US
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Telephone | 207-775-5671
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Fax |
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Provider Business Mailing Address
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Address Line | 16 ARCADIA DR
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City | WINDHAM
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State | ME
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Zip | 04062-5263
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Country | US
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Telephone | 207-615-1014
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CAC8987
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License Number State | ME
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | XL8138
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License Number State | ME
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