1598819989 NPI number — MISS DARLENE J WALLACE LCSW

Table of content: MISS DARLENE J WALLACE LCSW (NPI 1598819989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598819989 NPI number — MISS DARLENE J WALLACE LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
DARLENE
Provider Middle Name:
J
Provider Name Prefix Text:
MISS
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598819989
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6800 N WAUKESHA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60646-1528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-775-0097
Provider Business Mailing Address Fax Number:
847-413-0429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 E WOODFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 321
Provider Business Practice Location Address City Name:
SCHAUMBURG
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60173
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-775-0097
Provider Business Practice Location Address Fax Number:
847-413-0429
Provider Enumeration Date:
01/22/2007

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 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01671233 . This is a "BLUE CROSS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com