Provider Demographics
NPI:1083297774
Name:WALLACE, MYKALA R (LMSW)
Entity Type:Individual
Prefix:MS
First Name:MYKALA
Middle Name:R
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 W CLYDESDALE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-8209
Mailing Address - Country:US
Mailing Address - Phone:479-444-1670
Mailing Address - Fax:479-445-6903
Practice Address - Street 1:885 W CLYDESDALE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-8209
Practice Address - Country:US
Practice Address - Phone:479-444-1670
Practice Address - Fax:479-445-6903
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR10102-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker