Provider Demographics
NPI:1003512815
Name:WALLACE, STEVEN CURTIS (LLMSW)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:CURTIS
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 E HATHAWAY RD
Mailing Address - Street 2:
Mailing Address - City:HARBOR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49740-9570
Mailing Address - Country:US
Mailing Address - Phone:231-881-8246
Mailing Address - Fax:
Practice Address - Street 1:3890 CHARLEVOIX RD STE 306
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8423
Practice Address - Country:US
Practice Address - Phone:231-881-9125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511161171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical