Provider Demographics
NPI:1275031171
Name:WALLACE, MEGHAN ELIZABETH (LMSW)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:ELIZABETH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 LYELL AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606-2119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 LYELL AVENUE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606
Practice Address - Country:US
Practice Address - Phone:585-458-4200
Practice Address - Fax:585-277-0102
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101863104100000X
1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker