Provider Demographics
NPI:1710781901
Name:WALLACE, SEMAJ DALLAS
Entity type:Individual
Prefix:
First Name:SEMAJ
Middle Name:DALLAS
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-6022
Mailing Address - Country:US
Mailing Address - Phone:252-717-0579
Mailing Address - Fax:
Practice Address - Street 1:10 TAFT ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-6022
Practice Address - Country:US
Practice Address - Phone:252-717-0579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0732002481101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health