Individual
MICHELLE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
1340 NW WALL ST, BEND, OR 97703-1985
(541) 322-7500
(541) 322-7565
Mailing address
2577 NE COURTNEY DR, BEND, OR 97701-7752
(541) 322-7500
(541) 322-7565
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
1041C0700X
Clinical Social Worker
Primary
L11322
OR
Other
Enumeration date
08/23/2019
Last updated
04/17/2023
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