MEDICARE: LACEY L 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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1669197638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY L WALLACE

Provider Business Mailing Address
First Line	:	6926 SHANNON WILLOW RD STE 400
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-1335
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6926 SHANNON WILLOW RD STE 400
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-1335
Country	:	US
Telephone Number	:	704-981-2190
Fax Number	:

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

Provider Enumeration Date	:	10/11/2022
Last Update Date	:	10/11/2022

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Directions to “ LACEY L WALLACE ” Practice Location

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