Provider Demographics
NPI:1669134185
Name:WALLACE, CHEYNA MONET
Entity type:Individual
Prefix:
First Name:CHEYNA
Middle Name:MONET
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 1:41261 CANTON CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1474
Mailing Address - Country:US
Mailing Address - Phone:313-588-4808
Mailing Address - Fax:
Practice Address - Street 1:37450 SCHOOLCRAFT RD STE 110
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1000
Practice Address - Country:US
Practice Address - Phone:734-458-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker