MEDICARE: WILLIAM BLAINE-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	101YP2500X	Professional Counselor	XP4415	ME

General Provider Information

NPI Number	:	1730612839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM BLAINE-WALLACE

Provider Business Mailing Address
First Line	:	456 NEW VINEYARD RD
Second Line	:
City	:	FARMINGTON
State	:	ME
Zip	:	04938-5216
Country	:	US
Telephone Number	:	207-491-9645
Fax Number	:

Provider Business Practice Location Address
First Line	:	456 NEW VINEYARD RD
Second Line	:
City	:	FARMINGTON
State	:	ME
Zip	:	04938-5216
Country	:	US
Telephone Number	:	207-491-9645
Fax Number	:

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

Provider Enumeration Date	:	04/05/2017
Last Update Date	:	04/05/2017

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