Provider Demographics
NPI:1619541877
Name:WALLACE, CASEY
Entity type:Individual
Prefix:
First Name:CASEY
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 1:201 W NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48340-1154
Mailing Address - Country:US
Mailing Address - Phone:810-893-4363
Mailing Address - Fax:
Practice Address - Street 1:2045 E WEST MAPLE RD STE D405
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48390-3801
Practice Address - Country:US
Practice Address - Phone:248-669-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009880103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical