Individual
TYSHAUNDRA RENEE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.ED, LCASA, QP
Contact information
Practice address
1001 PHILLIPS AVE, HIGH POINT, NC 27262-7251
(336) 854-2560
Mailing address
438 DRUM RD APT 8, REIDSVILLE, NC 27320-9062
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
LCAS-25036
NC
Other
Enumeration date
02/05/2019
Last updated
02/05/2019
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