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General NPI Number Information
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NPI Number | 1992082416
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Entity Type | Individual
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Provider Name | SENETRA WALLACE LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/11/2011
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Last Update Date | 03/03/2015
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Provider Practice Location Address
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Address Line | 4909 WATERS EDGE DR 107
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City | RALEIGH
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State | NC
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Zip | 27606-2462
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Country | US
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Telephone | 919-247-9534
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Fax | 919-467-4219
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Provider Business Mailing Address
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Address Line | PO BOX 52271
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City | DURHAM
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State | NC
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Zip | 27717-2271
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Country | US
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Telephone | 919-247-9534
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Fax | 919-467-4219
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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 | C008919
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License Number State | NC
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