Provider Demographics
NPI:1003388455
Name:WALLACE, BETHANY (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:BETHANY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 LACE LN
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-6736
Mailing Address - Country:US
Mailing Address - Phone:817-739-1788
Mailing Address - Fax:
Practice Address - Street 1:4686 BRISTOL TRACE TRL
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6947
Practice Address - Country:US
Practice Address - Phone:817-705-1586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX616871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical