Provider Demographics
NPI:1750983177
Name:WALLACE, MEGAN OLIVIA
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:OLIVIA
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 1:616 2ND ST NW
Mailing Address - Street 2:
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663-1827
Mailing Address - Country:US
Mailing Address - Phone:330-407-5156
Mailing Address - Fax:
Practice Address - Street 1:1206 N MAIN ST STE 118
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-1926
Practice Address - Country:US
Practice Address - Phone:330-309-3133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician