Individual
KRISTIN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
940 EBENEZER BLVD, MADISON, MS 39110-6002
(601) 790-0583
Mailing address
437 PIN OAK DR, MADISON, MS 39110-9365
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
M8300
MS
Other
Enumeration date
08/05/2020
Last updated
08/05/2020
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