Individual
MR. MIKE THOMAS WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
L.P.C.
Contact information
Practice address
7075 W BELL RD, GLENDALE, AZ 85308-8546
(623) 810-4959
Mailing address
7075 W BELL RD, GLENDALE, AZ 85308-8546
(623) 810-4959
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
10676
AZ
Other
Enumeration date
05/30/2009
Last updated
05/30/2009
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