Provider Demographics
NPI:1659566164
Name:WALLACE, MARGUERITE THERESE (MSEA, LPCC-S)
Entity Type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:THERESE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSEA, LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 DRYDEN RD. THE FLEXMAN MYERS CLINIC
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45439
Mailing Address - Country:US
Mailing Address - Phone:937-256-5300
Mailing Address - Fax:937-258-4162
Practice Address - Street 1:2621 DRYDEN RD. THE FLEXMAN MYERS CLINIC
Practice Address - Street 2:SUITE 202
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45439
Practice Address - Country:US
Practice Address - Phone:937-256-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-07
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2893101YM0800X
OH0002893101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health