Individual
MR. GREGORY WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LCSWC
Contact information
Practice address
932 HUNGERFORD DR STE 18B, ROCKVILLE, MD 20850-1751
(301) 806-1892
(301) 468-1862
Mailing address
6005 CAMELBACK LN, COLUMBIA, MD 21045-3810
(301) 806-1892
(301) 468-1862
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
12531
MD
1041C0700X
Clinical Social Worker
Primary
12531
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
248050
KAISER
MD
05
—
406695200
—
MD
01
—
64403601
BCBS OF MD
MD
01
—
724490000
MAGELLAN
MD
01
—
7383677
AETNA
MD
01
—
A2840144
BCBS OF DC
DC
Enumeration date
08/13/2006
Last updated
03/02/2023
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