Provider Demographics
NPI:1083001721
Name:HEBERT-WALLACE, ALISSA (LCSW)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:HEBERT-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 1:6 LE BOURGEOIS DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8987
Mailing Address - Country:US
Mailing Address - Phone:601-317-6210
Mailing Address - Fax:
Practice Address - Street 1:6 LE BOURGEOIS DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-8987
Practice Address - Country:US
Practice Address - Phone:601-317-6210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI. 1500168104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker