Provider Demographics
NPI:1700069424
Name:WALLACE, MELISSA A (EDM)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 VICTORY RD
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-3518
Mailing Address - Country:US
Mailing Address - Phone:617-619-6921
Mailing Address - Fax:
Practice Address - Street 1:105 VICTORY RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3518
Practice Address - Country:US
Practice Address - Phone:617-619-6921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator