Individual
ROGER A WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MA
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
1179
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6107178
—
NC
Enumeration date
07/30/2007
Last updated
10/16/2008
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