Provider Demographics
NPI:1699454462
Name:WALLACE, MELANIE DRAKE (PHD, LPC-S, ACS,)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:DRAKE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHD, LPC-S, ACS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2531 WILLOWBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-3441
Mailing Address - Country:US
Mailing Address - Phone:205-994-4560
Mailing Address - Fax:
Practice Address - Street 1:600 CENTURY PARK S STE 200
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35226-3931
Practice Address - Country:US
Practice Address - Phone:205-999-5247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1250101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional