Provider Demographics
NPI:1093075913
Name:WALLACE, CYNTHIA (LICSW)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3338
Mailing Address - Country:US
Mailing Address - Phone:509-200-7290
Mailing Address - Fax:
Practice Address - Street 1:19 E BIRCH ST STE 103
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3084
Practice Address - Country:US
Practice Address - Phone:509-200-7290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000094761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical