Provider Demographics
NPI:1033799499
Name:WALLACE, MELLANI MARITZA
Entity Type:Individual
Prefix:
First Name:MELLANI
Middle Name:MARITZA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5749 RAYMOND BOLTON RD
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:MS
Mailing Address - Zip Code:39041-9253
Mailing Address - Country:US
Mailing Address - Phone:601-968-7032
Mailing Address - Fax:
Practice Address - Street 1:613 MARQUETTE RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-3038
Practice Address - Country:US
Practice Address - Phone:601-591-5553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-10
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor