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General NPI Number Information
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NPI Number | 1073135521
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Entity Type | Individual
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Provider Name | DONIELLE R WALLACE
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Gender | Female
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Dates
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Enumeration Date | 05/07/2020
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Last Update Date | 03/10/2025
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Provider Practice Location Address
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Address Line | 2135 DANA AVE STE 220
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City | CINCINNATI
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State | OH
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Zip | 45207-1342
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Country | US
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Telephone | 216-468-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 207D COLEGATE DR
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City | MARIETTA
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State | OH
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Zip | 45750-2363
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Country | US
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Telephone | 740-376-0930
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Fax | 740-376-0933
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | S.1904386
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I.2405894
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License Number State | OH
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