Provider Demographics
NPI:1225590672
Name:PRICE-WALLACE, BIANCA
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:PRICE-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 1:1924 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-4064
Mailing Address - Country:US
Mailing Address - Phone:734-678-1710
Mailing Address - Fax:313-792-8962
Practice Address - Street 1:1424 DURANGO DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-4492
Practice Address - Country:US
Practice Address - Phone:734-678-1710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101006175235Z00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty