Provider Demographics
NPI:1073135521
Name:WALLACE, DONIELLE R
Entity Type:Individual
Prefix:
First Name:DONIELLE
Middle Name:R
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 1:207D COLEGATE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-2363
Mailing Address - Country:US
Mailing Address - Phone:740-376-0930
Mailing Address - Fax:740-376-0933
Practice Address - Street 1:207D COLEGATE DR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-2363
Practice Address - Country:US
Practice Address - Phone:740-376-0930
Practice Address - Fax:740-376-0933
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1904386104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker