Provider Demographics
NPI:1235216482
Name:WALLACE, MELISSA M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 COMMERCIAL STREET
Mailing Address - Street 2:SUITE 3004
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-1118
Mailing Address - Country:US
Mailing Address - Phone:603-668-3050
Mailing Address - Fax:603-668-8666
Practice Address - Street 1:250 COMMERCIAL STREET
Practice Address - Street 2:SUITE 3004
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-1118
Practice Address - Country:US
Practice Address - Phone:603-668-3050
Practice Address - Fax:603-668-8666
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1165103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3080928Medicaid