NPIMap

Individual provider Active NPI

Margaret Susan Wallace

  • Mental Health Counselor
  • Fort Wayne, IN
National Provider Identifier
1639428931
Registry record updated Aug 31, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health CounselorTaxonomy code 101YM0800X
License
39002298A Issued in IN
Practice address
6315 Mutual Dr
Suite B
Fort Wayne, IN 46825-4238
Phone
(260) 409-8188
Fax
(866) 742-8426
NPI assigned
Aug 31, 2012
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Aug 31, 2012

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health Counselor 101YM0800X 39002298A IN Primary

Addresses

Primary practice location

6315 Mutual Dr
Suite B
Fort Wayne, IN 46825-4238

Mailing address

10214 Chestnut Plaza Dr
#130
Fort Wayne, IN 46814-8970
Phone (260) 409-8188

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled

State licenses

LicenseStateTypeSpecialty
39002298AINMDMental Health Counselor

Practice roles

OrganizationSpecialtyStatusNew patients
Prometheus Psychological Services Past Accepting new patients

Organizations & group practices 1

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.

NPI Registry JSON

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

{
    "created_epoch": "1346371200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1346371200000",
    "number": "1639428931",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10214 CHESTNUT PLAZA DR",
            "address_2": "#130",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468148970",
            "telephone_number": "260-409-8188",
            "fax_number": "866-742-8426"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6315 MUTUAL DR",
            "address_2": "SUITE B",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468254238",
            "telephone_number": "260-409-8188",
            "fax_number": "866-742-8426"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "MARGARET",
        "middle_name": "SUSAN",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-08-31",
        "last_updated": "2012-08-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "IN",
            "license": "39002298A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Wayne, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 31, 2012; 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.