Provider Demographics
NPI:1366974610
Name:WALLACE, CHRISTOPHER SCOTT (LCSW)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:SCOTT
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N 1ST AVE STE 2325
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-1933
Mailing Address - Country:US
Mailing Address - Phone:770-714-9847
Mailing Address - Fax:757-953-6091
Practice Address - Street 1:101 N 1ST AVE STE 2325
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-1933
Practice Address - Country:US
Practice Address - Phone:480-569-1604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD174431041C0700X
VA09040098721041C0700X
AZ228211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical