Provider Demographics
NPI:1700585726
Name:WALLACE, HEATHER L (CMS)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43605-2397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:732 MAIN ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43605-2397
Practice Address - Country:US
Practice Address - Phone:833-762-1013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)