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Individual
TY'CRISTIAN Q. WALLACE
Active
Individual
TY'CRISTIAN Q. WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LGPC, CAC-ADS
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
AC3232
MD
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
SC2995
MD
101YM0800X
Mental Health Counselor
Primary
LGP15614
MD
Other
Enumeration date
09/13/2022
Last updated
03/05/2026
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