Provider Demographics
NPI:1003116658
Name:WALLACE, MICHAEL EUGENE (MA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EUGENE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E. LIBERTY ST.
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104
Mailing Address - Country:US
Mailing Address - Phone:734-330-3580
Mailing Address - Fax:
Practice Address - Street 1:201 E LIBERTY ST
Practice Address - Street 2:SUITE 2
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2118
Practice Address - Country:US
Practice Address - Phone:734-330-3580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008847103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical