Individual
ICELINN PERDUE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
70 LAFAYETTE ST, PONTIAC, MI 48342-2033
(248) 338-7458
(248) 338-7513
Mailing address
2830 CORUNNA RD, FLINT, MI 48503-3254
(810) 235-6812
(810) 234-7022
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
680109826
MI
Other
Enumeration date
05/22/2009
Last updated
05/22/2009
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