1811127947 NPI number — MARY VIRGINIA WALLACE LCSW, ACSW

Table of content: MARY VIRGINIA WALLACE LCSW, ACSW (NPI 1811127947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811127947 NPI number — MARY VIRGINIA WALLACE LCSW, ACSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
MARY
Provider Middle Name:
VIRGINIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW, ACSW
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:
1811127947
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9927 BURNHAM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75243-2411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-442-6001
Provider Business Mailing Address Fax Number:
469-330-6405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 N CENTRAL EXPY
Provider Second Line Business Practice Location Address:
SUITE 375
Provider Business Practice Location Address City Name:
RICHARDSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75080-4669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-442-6001
Provider Business Practice Location Address Fax Number:
972-231-9009
Provider Enumeration Date:
07/23/2009

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:  30861 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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