Healthcare Provider Details

I. General information

NPI: 1760586176
Provider Name (Legal Business Name): TIFFANY LYNN WALLACE MS LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8623 N WAYNE ROAD HEGIRA PROGRAMS INC STE 310
WESTLAND MI
48185
US

IV. Provider business mailing address

11326 FORDLINE
ALLEN PARK MI
48101
US

V. Phone/Fax

Practice location:
  • Phone: 734-425-0636
  • Fax: 734-425-4771
Mailing address:
  • Phone: 313-590-6955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301012514
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: