Individual
TIFFANY LYNN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MS LLP
Contact information
Practice address
8623 N WAYNE ROAD, HEGIRA PROGRAMS INC STE 310, WESTLAND, MI 48185
(734) 425-0636
(734) 425-4771
Mailing address
11326 FORDLINE, ALLEN PARK, MI 48101
(313) 590-6955
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
6301012514
MI
Other
Enumeration date
09/08/2006
Last updated
07/08/2007
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