Provider Demographics
NPI:1730842733
Name:WALLACE, MELISSA ANN
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
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 1:6712 BALMORAL OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-6952
Mailing Address - Country:US
Mailing Address - Phone:703-309-5105
Mailing Address - Fax:
Practice Address - Street 1:6712 BALMORAL OVERLOOK
Practice Address - Street 2:
Practice Address - City:NEW MARKET
Practice Address - State:MD
Practice Address - Zip Code:21774-6952
Practice Address - Country:US
Practice Address - Phone:703-309-5105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-16
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD279371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical