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General NPI Number Information
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NPI Number | 1790845006
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Entity Type | Individual
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Provider Name | CAROL SEEBURGER WALLACE MA-LPC
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Gender | Female
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Dates
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Enumeration Date | 12/11/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 220 W ELLSWORTH ST
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City | MIDLAND
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State | MI
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Zip | 48640-5180
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Country | US
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Telephone | 989-837-0753
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Fax |
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Provider Business Mailing Address
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Address Line | 5496 N LAKE SANFORD RD
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City | SANFORD
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State | MI
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Zip | 48657-9327
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Country | US
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Telephone | 989-689-3557
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Fax |
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 6401005864
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License Number State | MI
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