Provider Demographics
NPI:1447725957
Name:WALLACE, MEGAN ELIZABETH
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:ELIZABETH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 KELSALL DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-7706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:784 KELSALL DR
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-7706
Practice Address - Country:US
Practice Address - Phone:912-308-0194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053516240106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician