MEDICARE: MR. MIKE THOMAS WALLACE L.P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	10676	AZ

General Provider Information

NPI Number	:	1043446420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MIKE THOMAS WALLACE L.P.C.

Provider Business Mailing Address
First Line	:	7075 W BELL RD
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-8546
Country	:	US
Telephone Number	:	623-810-4959
Fax Number	:

Provider Business Practice Location Address
First Line	:	7075 W BELL RD
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-8546
Country	:	US
Telephone Number	:	623-810-4959
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2009
Last Update Date	:	05/30/2009

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