MEDICARE: NICOLE JANEEN WALLACE LCMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	A13547	NC

General Provider Information

NPI Number	:	1154820868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE JANEEN WALLACE LCMHC

Provider Business Mailing Address
First Line	:	PO BOX 627
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27588-0627
Country	:	US
Telephone Number	:	919-306-2579
Fax Number	:	919-820-8571

Provider Business Practice Location Address
First Line	:	3041 BERKS WAY STE 102C
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27614-6777
Country	:	US
Telephone Number	:	919-925-2274
Fax Number	:	919-820-8571

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2018
Last Update Date	:	01/05/2021

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