Individual
FORMECIA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MS, MA, LCAS-A
Contact information
Practice address
618 E BOULEVARD, WILLIAMSTON, NC 27892-2736
(252) 792-0659
(252) 792-0660
Mailing address
1070 WYNN RD, WILLIAMSTON, NC 27892-8844
(252) 864-6835
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
25169
NC
Other
Enumeration date
02/20/2019
Last updated
03/05/2019
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