Provider Demographics
NPI:1881189181
Name:WALLACE, MELISSA SUE (SUDCC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:SUDCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 W WHITES BRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-1225
Mailing Address - Country:US
Mailing Address - Phone:559-264-5096
Mailing Address - Fax:
Practice Address - Street 1:2445 W WHITES BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-1225
Practice Address - Country:US
Practice Address - Phone:559-492-1373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9478101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)