Provider Demographics
NPI:1336871003
Name:WALLACE, MELISSA JAYNE (LMSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JAYNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4467 QUAIL HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-8622
Mailing Address - Country:US
Mailing Address - Phone:989-397-4524
Mailing Address - Fax:
Practice Address - Street 1:5024 N CENTER RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-9412
Practice Address - Country:US
Practice Address - Phone:989-790-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical