1659987238 NPI number — KIMBERLY WALLACE LPC LLC

Table of content: (NPI 1659987238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659987238 NPI number — KIMBERLY WALLACE LPC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIMBERLY WALLACE LPC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659987238
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4121 RIVERLOOK PKWY SE UNIT 206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30067-4534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-906-9831
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2852 JOHNSON FERRY RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30062-5686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-906-9831
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
404-906-9831

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)