MEDICARE: BETTY 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
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	923242	OH

General Provider Information

NPI Number	:	1760868061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETTY WALLACE

Provider Business Mailing Address
First Line	:	3688 WALES DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45405-1845
Country	:	US
Telephone Number	:	502-912-2674
Fax Number	:

Provider Business Practice Location Address
First Line	:	3688 WALES DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45405-1845
Country	:	US
Telephone Number	:	502-912-2674
Fax Number	:

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

Provider Enumeration Date	:	08/10/2015
Last Update Date	:	04/08/2019

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