Provider Demographics
NPI:1144232596
Name:WALLACE, CHERYL LECLEAR (MSW)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:LECLEAR
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 1:12411 N LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:CLIO
Mailing Address - State:MI
Mailing Address - Zip Code:48420-8240
Mailing Address - Country:US
Mailing Address - Phone:810-730-4023
Mailing Address - Fax:
Practice Address - Street 1:323 N STATE ST
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-1537
Practice Address - Country:US
Practice Address - Phone:989-673-6191
Practice Address - Fax:989-672-3053
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010822191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical