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Individual
MR. MICAH WALLACE
Active
Individual
MR. MICAH WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CDCA
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
181021
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
181021
CDCA
OH
Enumeration date
08/05/2021
Last updated
07/08/2022
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