Provider Demographics
NPI:1679771257
Name:WALLACE, TRUDY A
Entity Type:Individual
Prefix:
First Name:TRUDY
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 EPHRIAM ST
Mailing Address - Street 2:
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-4124
Mailing Address - Country:US
Mailing Address - Phone:330-708-3175
Mailing Address - Fax:330-385-3588
Practice Address - Street 1:15303 ST. RT 170
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-9216
Practice Address - Country:US
Practice Address - Phone:330-385-1000
Practice Address - Fax:330-385-3588
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor