Icelinn Perdue Wallace

Primary specialty

Social WorkerTaxonomy code 104100000X

License

680109826 Issued in MI

Practice address

70 Lafayette St
Pontiac, MI 48342-2033

Phone

(248) 338-7458

Fax

(248) 338-7513

NPI assigned

May 22, 2009

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Alternative Community Living, Inc.

  • Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
  • Flint, MI
  • NPI 1164718441
  NPD (past)
• Alternative Community Living, Inc.

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Flint, MI
  • NPI 1477769214
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1242950400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1242950400000",
    "number": "1376778100",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2830 CORUNNA RD",
            "city": "FLINT",
            "state": "MI",
            "postal_code": "485033254",
            "telephone_number": "810-235-6812",
            "fax_number": "810-234-7022"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "70 LAFAYETTE ST",
            "city": "PONTIAC",
            "state": "MI",
            "postal_code": "483422033",
            "telephone_number": "248-338-7458",
            "fax_number": "248-338-7513"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "ICELINN",
        "middle_name": "PERDUE",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2009-05-22",
        "last_updated": "2009-05-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "MI",
            "license": "680109826",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Walgreen
• Dequann Walker
• Kimberly Walker
• Kimberly Ann Walker, MA
• Walkers Home Care
• Joel Walthall, D.O.
• Huijuan Wang, MD
• Zehn Wani, MD
• Samuel M Wapner, O.D
• Lynnelle Ward, LMSW

• Social Worker in Pontiac, MI
• Providers in Pontiac, MI by specialty
• Social Worker in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 22, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.