| Kimberly Wallace Lpc Llc | |
|
2852 Johnson Ferry Rd Ste 100 Marietta GA 30062-5686 | |
| (404) 906-9831 | |
| Not Available |
| Full Name | Kimberly Wallace Lpc Llc |
|---|---|
| Speciality | Counselor |
| Location | 2852 Johnson Ferry Rd Ste 100, Marietta, Georgia |
| Authorized Official Name and Position | Kimberly Wallace (OWNER/PROVIDER) |
| Authorized Official Contact | 4049069831 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Kimberly Wallace Lpc Llc 2852 Johnson Ferry Rd Ste 100 Marietta GA 30062-5686 Ph: (404) 906-9831 | Kimberly Wallace Lpc Llc 2852 Johnson Ferry Rd Ste 100 Marietta GA 30062-5686 Ph: (404) 906-9831 |
| NPI Number | 1659987238 |
|---|---|
| Provider Enumeration Date | 09/19/2020 |
| Last Update Date | 11/24/2023 |
| Certification Date | 11/24/2023 |
| Medicare PECOS PAC ID | 6406290667 |
|---|---|
| Medicare Enrollment ID | O20240215004285 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1659987238 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | (* (Not Available)) | Primary |
| Provider Name | Kimberly Wallace |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1083091987 PECOS PAC ID: 7214371475 Enrollment ID: I20240215004330 |
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