Provider Demographics
NPI:1679356059
Name:WALLACE, JOY MICHELLE (QMHA)
Entity Type:Individual
Prefix:
First Name:JOY
Middle Name:MICHELLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 SW FORTH AVE
Mailing Address - Street 2:SUITE 520
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1813
Mailing Address - Country:US
Mailing Address - Phone:503-988-5464
Mailing Address - Fax:503-988-4386
Practice Address - Street 1:209 SW FORTH AVE
Practice Address - Street 2:SUITE 520
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1813
Practice Address - Country:US
Practice Address - Phone:503-988-5464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator