Provider Demographics
NPI:1598499626
Name:WALLACE, TRENTON J (AM)
Entity Type:Individual
Prefix:
First Name:TRENTON
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:M
Credentials:AM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3853 W 20TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-2935
Mailing Address - Country:US
Mailing Address - Phone:216-262-3846
Mailing Address - Fax:
Practice Address - Street 1:1744 PAYNE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-2910
Practice Address - Country:US
Practice Address - Phone:216-623-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X, 171M00000X
OHAPS.003298175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty