Provider Demographics
NPI:1336145432
Name:WALLACE, DIANA (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANA
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 1:1 NUNN DR
Mailing Address - Street 2:UNIVERSITY CENTER, SUITE 440
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41099-0002
Mailing Address - Country:US
Mailing Address - Phone:859-572-5650
Mailing Address - Fax:859-572-5615
Practice Address - Street 1:1 NUNN DR
Practice Address - Street 2:UNIVERSITY CENTER, SUITE 440
Practice Address - City:NEWPORT
Practice Address - State:KY
Practice Address - Zip Code:41099-0002
Practice Address - Country:US
Practice Address - Phone:859-572-5650
Practice Address - Fax:859-572-5615
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0051441041C0700X
KY36321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT800002846Medicare ID - Type Unspecified