Basic Information
| Provider Information | |||||||||
| NPI: | 1043612872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSWC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1113 HEALTHWAY DR | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218044470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
| FaxNumber: | 4103346362 | ||||||||
| Practice Location | |||||||||
| Address1: | 11120 SOMERSET AVE | ||||||||
| Address2: | |||||||||
| City: | PRINCESS ANNE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218532970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106514200 | ||||||||
| FaxNumber: | 4106514290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2014 | ||||||||
| LastUpdateDate: | 08/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 20375 | MD | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 20375 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | R968 | 01 | MD | CAREFIRST | OTHER | 7840093 | 01 | MD | AETNA | OTHER | 609550004 | 05 | MD | MEDICAID | 346646 | 01 | MD | TRICARE/MHN | OTHER |