Provider Demographics
NPI:1720289580
Name:WALLACE, COLLEEN CARVER (MS)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:CARVER
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 E PATTERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-1959
Mailing Address - Country:US
Mailing Address - Phone:937-292-7687
Mailing Address - Fax:
Practice Address - Street 1:1150 SCIOTO ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:OH
Practice Address - Zip Code:43078-2289
Practice Address - Country:US
Practice Address - Phone:937-652-4555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker