Provider Demographics
NPI:1619527611
Name:WALLACE, TIMOTHY (CDCA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:774 INTERNET DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-2589
Mailing Address - Country:US
Mailing Address - Phone:614-443-5454
Mailing Address - Fax:
Practice Address - Street 1:774 INTERNET DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-2589
Practice Address - Country:US
Practice Address - Phone:614-443-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2022-12-28
Deactivation Date:2022-12-21
Deactivation Code:
Reactivation Date:2022-12-28
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator