Basic Information
| Provider Information | |||||||||
| NPI: | 1841858875 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5440 EAGLE CLOUD TRL APT 301 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276063790 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 GARNER RD #107 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276103790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197876131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2019 | ||||||||
| LastUpdateDate: | 08/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 25403 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | A15095 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.