Provider Demographics
NPI:1033322987
Name:WALLACE & ASSOCIATES
Entity Type:Organization
Organization Name:WALLACE & ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-557-3820
Mailing Address - Street 1:16000 W 9 MILE RD
Mailing Address - Street 2:SUITE 615
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4808
Mailing Address - Country:US
Mailing Address - Phone:248-557-3820
Mailing Address - Fax:
Practice Address - Street 1:16000 W 9 MILE RD
Practice Address - Street 2:SUITE 615
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4808
Practice Address - Country:US
Practice Address - Phone:248-557-3820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPW05231103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty