Individual
MR. GREGORY WALLACE
Active
Individual
MR. GREGORY WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LCSWC
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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