Provider Demographics
NPI:1902938558
Name:WALLACE, TRIPHINIA M (PSY)
Entity Type:Individual
Prefix:
First Name:TRIPHINIA
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 JEFFERSON ST.
Mailing Address - Street 2:STE. 2C
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504
Mailing Address - Country:US
Mailing Address - Phone:617-379-0496
Mailing Address - Fax:617-807-0958
Practice Address - Street 1:8800 ROSWELL RD.
Practice Address - Street 2:STE. A135
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30350
Practice Address - Country:US
Practice Address - Phone:404-682-1923
Practice Address - Fax:678-669-2651
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2022-11-15
Deactivation Date:2022-08-17
Deactivation Code:
Reactivation Date:2022-11-15
Provider Licenses
StateLicense IDTaxonomies
GALPC003793101YP2500X
GAGA003723103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist