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Individual
CHARLES L WALLACE
Active
Individual
CHARLES L WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LADAC
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
3628
NM
Other
Enumeration date
11/15/2012
Last updated
05/22/2025
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