Provider Demographics
NPI:1447953435
Name:WALLACE, QUANESHA (LPC-R)
Entity type:Individual
Prefix:
First Name:QUANESHA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3105
Mailing Address - Country:US
Mailing Address - Phone:804-551-4292
Mailing Address - Fax:
Practice Address - Street 1:3143 MAGIC HOLLOW BLVD STE 100
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453-3077
Practice Address - Country:US
Practice Address - Phone:757-385-6940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704014373101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional