Provider Demographics
NPI:1497469597
Name:WALLACE, MIKELIA (MT-BC)
Entity Type:Individual
Prefix:
First Name:MIKELIA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12608 SE ALDER ST APT 60
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1688
Mailing Address - Country:US
Mailing Address - Phone:352-303-5352
Mailing Address - Fax:
Practice Address - Street 1:12608 SE ALDER ST APT 60
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1688
Practice Address - Country:US
Practice Address - Phone:352-303-5352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
16398225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist