Individual
SHATAVEA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
42 DELSEA DR S, GLASSBORO, NJ 08028-2621
(844) 422-3632
Mailing address
249 FIR TREE CT, EVESHAM, NJ 08053-2010
(856) 212-9082
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Enumeration date
10/11/2025
Last updated
10/11/2025
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