Provider Demographics
NPI:1609183714
Name:WALLACE, MICHELLE (BA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11191 ILLINOIS ROUTE 185
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62049-2664
Mailing Address - Country:US
Mailing Address - Phone:217-532-2001
Mailing Address - Fax:
Practice Address - Street 1:11191 ILLINOIS ROUTE 185
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:IL
Practice Address - Zip Code:62049-2664
Practice Address - Country:US
Practice Address - Phone:217-532-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health