Provider Demographics
NPI:1053748038
Name:WALLACE, TRACEY
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 WOLF TAIL CT SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-6547
Mailing Address - Country:US
Mailing Address - Phone:336-210-2957
Mailing Address - Fax:
Practice Address - Street 1:122 WOLF TAIL CT SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-6547
Practice Address - Country:US
Practice Address - Phone:336-210-2957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health