Provider Demographics
NPI:1477063444
Name:WALLACE, ERIN MELISSA (BS/CADC)
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:MELISSA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:BS/CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16338 N IL HIGHWAY 37
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-8178
Mailing Address - Country:US
Mailing Address - Phone:618-242-5835
Mailing Address - Fax:618-242-6392
Practice Address - Street 1:16338 N IL HIGHWAY 37
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-8178
Practice Address - Country:US
Practice Address - Phone:618-242-5835
Practice Address - Fax:618-242-6392
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1649404708Medicaid