MEDICARE: KRISTINA WALLACE

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	101YM0800X	Mental Health Counselor	0701011020	VA
2	101YP2500X	Professional Counselor	0701011020	VA

General Provider Information

NPI Number	:	1538890728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINA WALLACE

Provider Business Mailing Address
First Line	:	134 DOGWOOD DR
Second Line	:
City	:	CROSS JUNCTION
State	:	VA
Zip	:	22625-2501
Country	:	US
Telephone Number	:	130-252-8804
Fax Number	:

Provider Business Practice Location Address
First Line	:	134 DOGWOOD DR
Second Line	:
City	:	CROSS JUNCTION
State	:	VA
Zip	:	22625-2501
Country	:	US
Telephone Number	:	302-528-8047
Fax Number	:

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

Provider Enumeration Date	:	06/20/2022
Last Update Date	:	06/20/2022

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Directions to “ KRISTINA WALLACE ” Practice Location

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