Provider Demographics
NPI:1720762628
Name:WALLACE, ANIYA
Entity Type:Individual
Prefix:
First Name:ANIYA
Middle Name:
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 1:1500 S DOUGLAS RD # 230
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4108
Mailing Address - Country:US
Mailing Address - Phone:313-997-7103
Mailing Address - Fax:
Practice Address - Street 1:42850 GARFIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-5026
Practice Address - Country:US
Practice Address - Phone:844-854-1116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty