Provider Demographics
NPI:1760586176
Name:WALLACE, TIFFANY LYNN (MS LLP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11326 FORDLINE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101
Mailing Address - Country:US
Mailing Address - Phone:313-590-6955
Mailing Address - Fax:
Practice Address - Street 1:8623 N WAYNE ROAD
Practice Address - Street 2:HEGIRA PROGRAMS INC STE 310
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185
Practice Address - Country:US
Practice Address - Phone:734-425-0636
Practice Address - Fax:734-425-4771
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012514103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist