Provider Demographics
NPI:1033193545
Name:WALLACH, ANDREA EVE (LCSW MSW)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:EVE
Last Name:WALLACH
Suffix:
Gender:F
Credentials:LCSW MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 CHARLES PL
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3008
Mailing Address - Country:US
Mailing Address - Phone:847-246-6426
Mailing Address - Fax:847-256-6154
Practice Address - Street 1:115 S WILKE RD
Practice Address - Street 2:206 D
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-1532
Practice Address - Country:US
Practice Address - Phone:847-256-6426
Practice Address - Fax:847-967-0929
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001673683OtherBCBS
IL098768Medicare ID - Type Unspecified