MEDICARE: MARY 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	103TS0200X	School Psychologist

General Provider Information

NPI Number	:	1528585031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY WALLACE

Provider Business Mailing Address
First Line	:	1605 E ASH ST
Second Line	:
City	:	CANTON
State	:	IL
Zip	:	61520-1510
Country	:	US
Telephone Number	:	309-647-6951
Fax Number	:

Provider Business Practice Location Address
First Line	:	1605 E ASH ST
Second Line	:
City	:	CANTON
State	:	IL
Zip	:	61520-1510
Country	:	US
Telephone Number	:	309-647-6951
Fax Number	:

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

Provider Enumeration Date	:	08/25/2017
Last Update Date	:	07/21/2022

Similar Medicare Providers

1174831218 — CANTON PHYSICAL MEDICARE, LLC
Practice Location Address:

2050 CUMMING HWY , SUITE 100
CANTON, GA
30114-8614

Practice Phone: 770-345-9600
Practice Fax:

1063473635 — RENAISSANCE CARE CENTER, INC
Practice Location Address:

1675 E ASH ST
CANTON, IL
61520-1510

Practice Phone: 309-647-5631
Practice Fax: 309-647-8957

1366694267 — RENAISSANCE CARE CENTER
Practice Location Address:

1675 E ASH ST
CANTON, IL
61520-1510

Practice Phone: 309-647-5631
Practice Fax: 309-641-8957

1174778690 — RENAISSANCE CARE CENTER
Practice Location Address:

1675 E ASH ST
CANTON, IL
61520-1510

Practice Phone: 309-647-5631
Practice Fax:

1801288915 — RENAISSANCE CARE CENTER, INC
Practice Location Address:

1675 E ASH ST
CANTON, IL
61520-1510

Practice Phone: 309-647-5631
Practice Fax: 309-647-8957

1962014977 — MAKENZIE MAYALL
Practice Location Address:

1605 E ASH ST
CANTON, IL
61520-1510

Practice Phone: 309-647-6951
Practice Fax:

Directions to “ MARY WALLACE ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.