Provider Demographics
NPI:1326353442
Name:WALLACE, VICTORIA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:
Last Name: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 1:112 DESIRABLE LANE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203
Mailing Address - Country:US
Mailing Address - Phone:318-651-9866
Mailing Address - Fax:
Practice Address - Street 1:112 DESIRABLE LANE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203
Practice Address - Country:US
Practice Address - Phone:318-651-9866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA67721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical