Provider Demographics
NPI:1477610285
Name:WALLACE, MICHAEL DAVID (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3022 N 81ST ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4810
Mailing Address - Country:US
Mailing Address - Phone:414-449-1491
Mailing Address - Fax:
Practice Address - Street 1:10850 W PARK PL
Practice Address - Street 2:SUITE # 100
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-3606
Practice Address - Country:US
Practice Address - Phone:262-542-3255
Practice Address - Fax:414-359-1021
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2578-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical