Provider Demographics
NPI:1306187539
Name:WALLACE, BRENNA MICHEL (MSW)
Entity Type:Individual
Prefix:MS
First Name:BRENNA
Middle Name:MICHEL
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 1:8220 CASTOR AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2729
Mailing Address - Country:US
Mailing Address - Phone:215-847-2249
Mailing Address - Fax:215-745-6511
Practice Address - Street 1:8220 CASTOR AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19152-2729
Practice Address - Country:US
Practice Address - Phone:215-847-2249
Practice Address - Fax:215-745-6511
Is Sole Proprietor?:No
Enumeration Date:2013-03-13
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker