Provider Demographics
NPI:1083365811
Name:MARTIN-WALLACE, DONNA LOUISE (LPCC, LADC, ADCR-MN)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:LOUISE
Last Name:MARTIN-WALLACE
Suffix:
Gender:F
Credentials:LPCC, LADC, ADCR-MN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14024 NATCHEZ AVE
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2002
Mailing Address - Country:US
Mailing Address - Phone:612-220-3247
Mailing Address - Fax:
Practice Address - Street 1:2970 JUDICIAL RD STE 100
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-7822
Practice Address - Country:US
Practice Address - Phone:952-224-8990
Practice Address - Fax:952-224-8991
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC03103101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty