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NPI Code Detail

MEDICARE: MRS. ELIZABETH DASHIELL WALLACE RN, LPC

MEDICARE: MRS. ELIZABETH DASHIELL WALLACE RN, LPC
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
1101YP2500XProfessional Counselor4656SC

General Provider Information

NPI Number : 1376783118
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. ELIZABETH DASHIELL WALLACE RN, LPC
Provider Business Mailing Address
First Line : 360 E KILLARNEY LK
Second Line :
City : MOORE
State : SC
Zip : 29369-9489
Country : US
Telephone Number : 864-804-8381
Fax Number : 864-804-8381
Provider Business Practice Location Address
First Line : 429 N CHURCH ST
Second Line :
City : SPARTANBURG
State : SC
Zip : 29303-3612
Country : US
Telephone Number : 864-597-4371
Fax Number : 864-597-4379
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/05/2009
Last Update Date : 03/05/2009

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