Provider Demographics
NPI:1043906027
Name:WALLACE, SIMONE
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SIMONE
Other - Middle Name:
Other - Last Name:STITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1044 27TH AVE SE APT D
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2736
Mailing Address - Country:US
Mailing Address - Phone:612-508-9723
Mailing Address - Fax:
Practice Address - Street 1:1044 27TH AVE SE APT D
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-2736
Practice Address - Country:US
Practice Address - Phone:612-508-9723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor