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General NPI Number Information
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NPI Number | 1588492664
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Entity Type | Individual
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Provider Name | AMAYA O. WALLACE LCSW-A, LCAS
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Gender | Female
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Dates
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Enumeration Date | 07/22/2024
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Last Update Date | 08/21/2025
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Provider Practice Location Address
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Address Line | 6118 SAINT GILES ST STE 120
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City | RALEIGH
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State | NC
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Zip | 27612-7045
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Country | US
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Telephone | 984-278-8449
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Fax |
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Provider Business Mailing Address
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Address Line | 6118 SAINT GILES ST STE 120
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City | RALEIGH
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State | NC
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Zip | 27612-7045
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Country | US
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Telephone |
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State | NC
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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 |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 374J00000X
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Taxonomy Name | Doula
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State | NC
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