1700898012 NPI number — MR. GREGORY WALLACE LCSWC

Table of content: MR. GREGORY WALLACE LCSWC (NPI 1700898012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700898012 NPI number — MR. GREGORY WALLACE LCSWC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
GREGORY
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSWC
Provider Gender Code:
M

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:
1700898012
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6005 CAMELBACK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21045-3810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-806-1892
Provider Business Mailing Address Fax Number:
301-468-1862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
932 HUNGERFORD DR STE 18B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20850-1751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-806-1892
Provider Business Practice Location Address Fax Number:
301-468-1862
Provider Enumeration Date:
08/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  12531 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 12531 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 248050 . This is a "KAISER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 406695200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64403601 . This is a "BCBS OF MD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 7383677 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 724490000 . This is a "MAGELLAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: A2840144 . This is a "BCBS OF DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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