Provider Demographics
NPI:1780807727
Name:WALLACE, STEPHANIE DAWN (SW)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:DAWN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 SE WHISPERING WILLOWS DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8599
Mailing Address - Country:US
Mailing Address - Phone:336-641-6370
Mailing Address - Fax:336-641-6693
Practice Address - Street 1:1203 MAPLE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6910
Practice Address - Country:US
Practice Address - Phone:336-641-6370
Practice Address - Fax:336-641-6693
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker