Provider Demographics
NPI:1922334119
Name:MILLER, WALLACE MARTIN (MS)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:MARTIN
Last Name:MILLER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 S RURAL RD
Mailing Address - Street 2:TEMPE ELEMENTARY SCHOOL DISTRICT # 3
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-3853
Mailing Address - Country:US
Mailing Address - Phone:480-730-7287
Mailing Address - Fax:
Practice Address - Street 1:2130 E HOWE AVE
Practice Address - Street 2:THEW ELEMENTARY SCHOOL
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-4818
Practice Address - Country:US
Practice Address - Phone:480-730-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3489934101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool