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NPI Code Detail

MEDICARE: DONIELLE R WALLACE

MEDICARE: DONIELLE R WALLACE
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
1104100000XSocial WorkerS.1904386OH
21041C0700XClinical Social WorkerI.2405894OH

General Provider Information

NPI Number : 1073135521
Entity Type Code : Individual
Provider Name (Legal Business Name) : DONIELLE R WALLACE
Provider Business Mailing Address
First Line : 207D COLEGATE DR
Second Line :
City : MARIETTA
State : OH
Zip : 45750-2363
Country : US
Telephone Number : 740-376-0930
Fax Number : 740-376-0933
Provider Business Practice Location Address
First Line : 2135 DANA AVE STE 220
Second Line :
City : CINCINNATI
State : OH
Zip : 45207-1342
Country : US
Telephone Number : 216-468-5000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/07/2020
Last Update Date : 03/10/2025

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Directions to “ DONIELLE R WALLACE ” Practice Location

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