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NPI Code Detail

MEDICARE: MICHELLE WALLACE

MEDICARE: MICHELLE 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
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1629927389
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHELLE WALLACE
Provider Business Mailing Address
First Line : 526 CHANDLER ST
Second Line :
City : WINSTON SALEM
State : NC
Zip : 27101-1906
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 720 COLISEUM DR STE 92
Second Line :
City : WINSTON SALEM
State : NC
Zip : 27106-5357
Country : US
Telephone Number : 743-255-4568
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/26/2026
Last Update Date : 01/26/2026

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Directions to “ MICHELLE WALLACE ” Practice Location

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