Provider Demographics
NPI:1982098570
Name:WALLNER, RACHEL
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:WALLNER
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 1:500 TOWN CENTER DR
Mailing Address - Street 2:SUITE 425
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2737
Mailing Address - Country:US
Mailing Address - Phone:313-240-9635
Mailing Address - Fax:
Practice Address - Street 1:1460 COOLIDGE HWY
Practice Address - Street 2:
Practice Address - City:RIVER ROUGE
Practice Address - State:MI
Practice Address - Zip Code:48218-1118
Practice Address - Country:US
Practice Address - Phone:313-843-1639
Practice Address - Fax:313-843-1649
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010975801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical