Provider Demographics
NPI:1861804320
Name:WALLACE, SARA (EDS)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 SWITCHBACK CT
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-4315
Mailing Address - Country:US
Mailing Address - Phone:330-509-1617
Mailing Address - Fax:
Practice Address - Street 1:6506 STATE ROUTE 229
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:OH
Practice Address - Zip Code:43334-9738
Practice Address - Country:US
Practice Address - Phone:419-768-3040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3151539103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool