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NPI Code Detail

MEDICARE: MEGAN A WALLACE BA

MEDICARE: MEGAN A WALLACE BA
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
1101YA0400XAddiction (Substance Use Disorder) Counselor15367-131WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1962697185
Entity Type Code : Individual
Provider Name (Legal Business Name) : MEGAN A WALLACE BA
Provider Business Mailing Address
First Line : 7330 W LAYTON AVE
Second Line :
City : MILWAUKEE
State : WI
Zip : 53220-3849
Country : US
Telephone Number : 414-877-1071
Fax Number :
Provider Business Practice Location Address
First Line : 7330 W LAYTON AVE
Second Line :
City : MILWAUKEE
State : WI
Zip : 53220-3849
Country : US
Telephone Number : 414-877-1071
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/11/2007
Last Update Date : 12/16/2019

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