Provider Demographics
NPI:1619271228
Name:WALLACE, DEBRA J (PCC-S, LICDC)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PCC-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-453-8252
Mailing Address - Fax:330-453-6716
Practice Address - Street 1:1207 W STATE ST
Practice Address - Street 2:SUITE F
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4686
Practice Address - Country:US
Practice Address - Phone:330-821-3846
Practice Address - Fax:330-821-5172
Is Sole Proprietor?:No
Enumeration Date:2010-12-23
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0900224-SUPV101YP2500X
OHLICDC.151044-CS101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0182777Medicaid