Provider Demographics
NPI:1326290982
Name:WALLACE, SHANNON MCNALLY (MSW, LCSW, LCAS, CCS)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MCNALLY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSW, LCSW, LCAS, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LANDSTUHL REGIONAL MEDICAL CENTER
Mailing Address - Street 2:UNIT 33100
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-3100
Mailing Address - Country:US
Mailing Address - Phone:314-590-5022
Mailing Address - Fax:
Practice Address - Street 1:LANDSTUHL REGIONAL MEDICAL CENTER
Practice Address - Street 2:UNIT 33100
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-3100
Practice Address - Country:US
Practice Address - Phone:314-590-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0045621041C0700X
NCC0068651041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007780Medicaid