Provider Demographics
NPI:1083394316
Name:WALLACE, JULIA (MSW)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1684 SHOEMAKER DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-7708
Mailing Address - Country:US
Mailing Address - Phone:734-756-8238
Mailing Address - Fax:
Practice Address - Street 1:2006 HOGBACK RD STE 8
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9750
Practice Address - Country:US
Practice Address - Phone:734-559-3540
Practice Address - Fax:734-667-3925
Is Sole Proprietor?:No
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68510919921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical