Provider Demographics
NPI:1023558103
Name:WALLACE, ALLISON (MSW, MFT)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSW, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2456 HEARTHSTEAD LN
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45239-6616
Mailing Address - Country:US
Mailing Address - Phone:404-798-1055
Mailing Address - Fax:
Practice Address - Street 1:2456 HEARTHSTEAD LN
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45239-6616
Practice Address - Country:US
Practice Address - Phone:404-798-1055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.16007161041C0700X
GACSW0055551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical