Provider Demographics
NPI:1053803312
Name:WALLACE, LIONEL JR
Entity type:Individual
Prefix:
First Name:LIONEL
Middle Name:
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1887 SAVANNAH LN
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3678
Mailing Address - Country:US
Mailing Address - Phone:734-395-9282
Mailing Address - Fax:
Practice Address - Street 1:5577 WHITTAKER RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-9752
Practice Address - Country:US
Practice Address - Phone:734-395-9282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-03
Last Update Date:2018-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101002558235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist