Provider Demographics
NPI:1407154768
Name:WALLACE, PAMELA MICHELLE
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:MICHELLE
Last Name: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 1:917 BLUE HILL AVE
Mailing Address - Street 2:#5
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-2948
Mailing Address - Country:US
Mailing Address - Phone:617-980-4662
Mailing Address - Fax:
Practice Address - Street 1:917 BLUE HILL AVE
Practice Address - Street 2:#5
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-2948
Practice Address - Country:US
Practice Address - Phone:617-980-4662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health