Provider Demographics
NPI:1639428931
Name:WALLACE, MARGARET SUSAN
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:SUSAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10214 CHESTNUT PLAZA DR
Mailing Address - Street 2:#130
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8970
Mailing Address - Country:US
Mailing Address - Phone:260-409-8188
Mailing Address - Fax:866-742-8426
Practice Address - Street 1:6315 MUTUAL DR
Practice Address - Street 2:SUITE B
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-4238
Practice Address - Country:US
Practice Address - Phone:260-409-8188
Practice Address - Fax:866-742-8426
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002298A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health