Provider Demographics
NPI:1043446420
Name:WALLACE, MIKE THOMAS (LPC)
Entity type:Individual
Prefix:MR
First Name:MIKE
Middle Name:THOMAS
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7075 W BELL RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8546
Mailing Address - Country:US
Mailing Address - Phone:623-810-4959
Mailing Address - Fax:
Practice Address - Street 1:7075 W BELL RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8546
Practice Address - Country:US
Practice Address - Phone:623-810-4959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-30
Last Update Date:2009-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10676101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health