Individual
CHARLES L WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LADAC
Contact information
Practice address
653 W ARRINGTON ST, FARMINGTON, NM 87401-8513
(505) 564-3733
Mailing address
653 W ARRINGTON ST, FARMINGTON, NM 87401-8513
(505) 564-3733
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
3628
NM
Other
Enumeration date
11/15/2012
Last updated
05/22/2025
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