Provider Demographics
NPI:1417265463
Name:BEAUCHAMP, WALLACE A III (LCSW)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:A
Last Name:BEAUCHAMP
Suffix:III
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 E BROADWAY BLVD
Mailing Address - Street 2:STE. 180
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-5863
Mailing Address - Country:US
Mailing Address - Phone:520-624-5806
Mailing Address - Fax:520-624-5817
Practice Address - Street 1:1475 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-7236
Practice Address - Country:US
Practice Address - Phone:520-624-5806
Practice Address - Fax:520-624-5817
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW 115761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical