Healthcare Provider Details

I. General information

NPI: 1548934227
Provider Name (Legal Business Name): MICAH WALLACE CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 SYCAMORE ST
CINCINNATI OH
45202-1305
US

IV. Provider business mailing address

311 ALBERT SABIN WAY
CINCINNATI OH
45229-2838
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-9006
  • Fax: 513-558-3880
Mailing address:
  • Phone: 513-558-9006
  • Fax: 513-558-3880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number181021
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: