Provider Demographics
NPI:1912737974
Name:WALLACE, KALEIGH
Entity type:Individual
Prefix:
First Name:KALEIGH
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 GRAHAM ROAD CIR
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-2933
Mailing Address - Country:US
Mailing Address - Phone:330-928-0044
Mailing Address - Fax:
Practice Address - Street 1:1100 GRAHAM ROAD CIR
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-2933
Practice Address - Country:US
Practice Address - Phone:330-928-0044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2405531104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker