Provider Demographics
NPI:1548934227
Name:WALLACE, MICAH (CDCA)
Entity type:Individual
Prefix:MR
First Name:MICAH
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 ALBERT SABIN WAY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-2838
Mailing Address - Country:US
Mailing Address - Phone:513-558-9006
Mailing Address - Fax:513-558-3880
Practice Address - Street 1:909 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202-1305
Practice Address - Country:US
Practice Address - Phone:513-558-9006
Practice Address - Fax:513-558-3880
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH181021171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH181021OtherCDCA