Individual
ROGER A WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MA
Contact information
Practice address
410 MILLS GAP RD., ARDEN, NC 28704
(828) 654-0111
(828) 654-0111
Mailing address
PO BOX 127, ARDEN, NC 28704-0127
(828) 654-0111
(828) 654-0111
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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