CHARLES L WALLACE (NPI# 1902140932) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1902140932 |
| Entity Type | Individual |
| Full Name | CHARLES L WALLACE |
| Credential | LADAC |
| Practice Address |
2901 E. 20th Suite 104 Farmington NM 87499 |
| Mailing Address |
P.o. Box 3602 Farmington NM 87499 |
| Practice Telephone | 5053260241 |
| Practice Fax Number | 5053258356 |
| Enumeration Date | 2012-11-15 |
| Last Update Date | 2012-11-15 |
| Gender Code | M |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 101YA0400X |
Counselor Specialization: Addiction (Substance Use Disorder) |
3628 | NM | Behavioral Health & Social Service Providers |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1073643862 | Charles Wayne Wallace | Dentist | 502 N Coalter St, Staunton, VA 24401-3401 | 2007-03-07 |
| 1063584746 | Charles E Wallace | Dentist | 3221 Eastlake Ave E Ste 130, Seattle, WA 98102-7125 | 2006-11-15 |
| 1164422481 | Charles Alan Wallace | Surgery | 17110 Dallas Pkwy, Suite 100, Dallas, TX 75248-1167 | 2005-07-28 |
| 1144229600 | Charles Douglas Wallace | Orthopaedic Surgery | 3030 Childrens Way, Ste 410, San Diego, CA 92123-4232 | 2005-07-18 |
| 1780125203 | Charles Jerome Wallace | Counselor | 55 W 125th St Fl 11, New York, NY 10027-4516 | 2017-03-16 |
| 1851506463 | Charles William Wallace | Marriage & Family Therapist | 5738 Olde Wadsworth Blvd, Arvada, CO 80002-2535 | 2007-05-14 |
| 1578621231 | Charles R. Wallace Jr. | Urology | 1325 Eastmoreland Ave, Suite 425, Memphis, TN 38104-3519 | 2006-12-05 |
| 1881702736 | Charles T Wallace | Anesthesiology | 171 Ashley Ave, Charleston, SC 29425-0001 | 2006-08-29 |
| 1780652792 | Charles W Wallace | Family Medicine | 4455 Dressler Rd Nw, Canton, OH 44718-2785 | 2006-03-08 |
| Street Address |
2901 E. 20TH SUITE 104 |
| City | FARMINGTON |
| State | NM |
| Zip Code | 87499 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1831588771 | Maria Bundy | Counselor | 1615 Ojo Court, Farmington, NM 87499 | 2015-01-15 |
| 1710020300 | Ernestine Platero | Counselor | 1615 Ojo Court, Farmington, NM 87499 | 2007-02-14 |
| 1326195769 | Pms Dba Roundtree Childrens' Development Services | Clinic/Center | 608 Reilly Ave, Farmington, NM 87499 | 2007-01-05 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1336740653 | Personal Growth Services | Community/Behavioral Health | 57 Metacomet Rd, Farmington, CT 06032-1801 | 2020-11-03 |
| 1093316333 | Barbara J Dadisman | Technician | 364 Parrish Run Rd, Farmington, WV 26571-8097 | 2020-11-03 |
| 1508466368 | Amalia Jo Folland Harvey | Nurse Practitioner | 19883 Evensong Ct, Farmington, MN 55024-8688 | 2020-10-29 |
| 1649870056 | Great Oaks Academy | Local Education Agency (LEA) | 6300 212th St W, Farmington, MN 55024-8903 | 2020-10-27 |
| 1912507153 | Legacy Heights Oral & Facial Surgery Pllc | Clinic/Center | 193 S 200 W Ste B, Farmington, UT 84025-2406 | 2020-10-27 |
| 1548869068 | Marian Kinsel | Behavior Technician | 5107 Loma Alto Dr, Farmington, NM 87402-8344 | 2020-10-26 |
| 1366041360 | Christine Mullin | Social Worker | 883 Plainville Ave, Farmington, CT 06032-3121 | 2020-10-21 |
| 1093314254 | Elise Vallejos | Behavior Technician | 6905 Alyssa Ct, Farmington, NM 87402-5088 | 2020-10-20 |
| 1356940787 | Carrie Boehm | Dental Hygienist | 2844 E Main St Ste 106-145, Farmington, NM 87402-5260 | 2020-10-16 |
| 1063010726 | Daniela Villagran | Behavior Technician | 303 N Lorena Ave, Farmington, NM 87401-5858 | 2020-10-15 |
| Find all providers in FARMINGTON | ||||
| Taxonomy Code | 101YA0400X |
| Grouping | Behavioral Health & Social Service Providers |
| Classification | Counselor |
| Specialization | Addiction (Substance Use Disorder) |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1265077275 | Jerrald Tom James | Counselor | 475 E 20th St Ste D, Farmington, NM 87401-2132 | 2019-11-13 |
| 1063071041 | Daphnie Cummins | Counselor | 653 W Arrington St, Farmington, NM 87401-8513 | 2019-06-12 |
| 1306323555 | Litany of Life | Counselor | 1010 Ridgeway Place, Farmington, NM 87401 | 2018-07-20 |
| 1801327614 | Holly Gregory | Counselor | 216 E Apache St, Farmington, NM 87401-6904 | 2017-03-23 |
| 1306382007 | Lisa Lippold | Counselor | 20333 Enright Way, Farmington, MN 55024-2022 | 2017-01-18 |
| 1922455609 | Second Chance Counseling, LLC | Counselor | 719 W Apache St, Farmington, NM 87401-5512 | 2016-05-23 |
| 1790131977 | Shawna B Riley | Counselor | 1313 Mission Ave, Farmington, NM 87401 | 2016-05-06 |
| 1437516911 | Ann Cushing | Counselor | 253 Fairbanks Rd, Farmington, ME 04938-5723 | 2016-01-28 |
| 1922499136 | Masada House Inc | Counselor | 610 N Dustin Ave, Farmington, NM 87401 | 2015-02-10 |
| 1194128603 | Ag Counseling LLC | Counselor | 769 Farmington Ave, Farmington, CT 06032-2310 | 2014-09-29 |
| Find all providers in FARMINGTON | ||||
| City | FARMINGTON |
| Zip Code | 87499 |
Please comment or provide details below to improve the information on CHARLES L WALLACE.
| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.