Provider Demographics
NPI:1538890728
Name:WALLACE, KRISTINA
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CROSS JUNCTION
Mailing Address - State:VA
Mailing Address - Zip Code:22625-2501
Mailing Address - Country:US
Mailing Address - Phone:130-252-8804
Mailing Address - Fax:
Practice Address - Street 1:134 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:CROSS JUNCTION
Practice Address - State:VA
Practice Address - Zip Code:22625-2501
Practice Address - Country:US
Practice Address - Phone:302-528-8047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701011020101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health