Basic Information
| Provider Information | |||||||||
| NPI: | 1013459940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30243 CAMPBELL ST | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480932585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103058531 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 38600 VAN DYKE AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483121171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006931916 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2016 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801096486 | MI | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 6801096486 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.