Provider Demographics
NPI:1073759429
Name:WALLACE, CODIE (MSW)
Entity Type:Individual
Prefix:
First Name:CODIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:CODIE
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2510 E 15TH ST
Mailing Address - Street 2:SUITE 11
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4111
Mailing Address - Country:US
Mailing Address - Phone:307-234-9979
Mailing Address - Fax:307-234-9989
Practice Address - Street 1:2510 E 15TH ST
Practice Address - Street 2:SUITE 11
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4111
Practice Address - Country:US
Practice Address - Phone:307-234-9979
Practice Address - Fax:307-234-9989
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WYLCSW 8001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator