Provider Demographics
NPI:1619527611
Name:WALLACE, TIMOTHY JR (EDD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 S HIGH ST STE 220
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5644
Mailing Address - Country:US
Mailing Address - Phone:614-625-7183
Mailing Address - Fax:
Practice Address - Street 1:580 S HIGH ST STE 220
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5644
Practice Address - Country:US
Practice Address - Phone:614-625-7183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2025-01-22
Deactivation Date:2022-12-21
Deactivation Code:
Reactivation Date:2022-12-28
Provider Licenses
StateLicense IDTaxonomies
OHE.2504990101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional