Provider Demographics
NPI:1790947992
Name:WALLACE, MELISSA E (PCC)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:E
Other - Last Name:TOTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PCC
Mailing Address - Street 1:25101 CHAGRIN BOULEVARD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-6052
Mailing Address - Country:US
Mailing Address - Phone:216-831-6611
Mailing Address - Fax:216-456-8128
Practice Address - Street 1:25101 CHAGRIN BOULEVARD
Practice Address - Street 2:SUITE 100
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-6052
Practice Address - Country:US
Practice Address - Phone:216-831-6611
Practice Address - Fax:216-456-8128
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-28
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health