MEDICARE: MRS. LISA BUCKNER WALLACE LCMHCA

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	A13854	NC

General Provider Information

NPI Number	:	1598225930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA BUCKNER WALLACE LCMHCA

Provider Business Mailing Address
First Line	:	200 E 2ND AVE
Second Line	:
City	:	GASTONIA
State	:	NC
Zip	:	28052-4358
Country	:	US
Telephone Number	:	704-874-1900
Fax Number	:

Provider Business Practice Location Address
First Line	:	3750 N CENTER ST
Second Line	:
City	:	HICKORY
State	:	NC
Zip	:	28601-8089
Country	:	US
Telephone Number	:	828-327-3491
Fax Number	:

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

Provider Enumeration Date	:	03/21/2019
Last Update Date	:	08/11/2020

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