1528107471 NPI number — HEIDI ALLISON WILKEN WALLACE LCSW

Table of content: HEIDI ALLISON WILKEN WALLACE LCSW (NPI 1528107471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528107471 NPI number — HEIDI ALLISON WILKEN WALLACE LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
HEIDI
Provider Middle Name:
ALLISON WILKEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILKEN
Provider Other First Name:
HEIDI
Provider Other Middle Name:
ALLISON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528107471
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27566 1375 EAST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALNUT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61376-9528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-383-7277
Provider Business Mailing Address Fax Number:
815-379-2184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27566 1375 EAST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALNUT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61376-9528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-383-7277
Provider Business Practice Location Address Fax Number:
815-379-2184
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  149012947 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 222Q00000X , with the licence number: HW49060306P , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HW49060306P . This is a "EARLY INTERVENTION" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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