Provider Demographics
NPI:1356760037
Name:JILL N WALLACE LCSW PLLC
Entity type:Organization
Organization Name:JILL N WALLACE LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:N
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:516-459-0312
Mailing Address - Street 1:15 HEATH LN
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-1912
Mailing Address - Country:US
Mailing Address - Phone:516-459-0312
Mailing Address - Fax:
Practice Address - Street 1:15 HEATH LN
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-1912
Practice Address - Country:US
Practice Address - Phone:516-459-0312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-10
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR045832104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty