Provider Demographics
NPI:1417529918
Name:WALLACE, DOROTHY ARLENE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:ARLENE
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 1:35 S PIONEER ST
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33917-2617
Mailing Address - Country:US
Mailing Address - Phone:978-270-4132
Mailing Address - Fax:
Practice Address - Street 1:13 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-2121
Practice Address - Country:US
Practice Address - Phone:978-270-4132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1145371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical