Provider Demographics
NPI:1437513884
Name:WALLACE, NATALIE MARIE (LMSW,MSW,BA)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMSW,MSW,BA
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:141 E MAIN ST
Mailing Address - Street 2:4TH FLOOR ADMINISTRATION
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2310
Mailing Address - Country:US
Mailing Address - Phone:203-574-9000
Mailing Address - Fax:203-574-9006
Practice Address - Street 1:72 WEST ST
Practice Address - Street 2:DANBURY CLINICAL SERVICES
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6531
Practice Address - Country:US
Practice Address - Phone:203-797-9778
Practice Address - Fax:203-797-9858
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-08-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY061366104100000X
CT3302104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD339229 DANBURYOtherBEACON HEALTH STRATEGIES
CTNOT ELIGIBLEOtherMHN MANAGED HEALTH NETWORK
CTPENDINGMedicaid
CT060669107OtherHEALTHYCT WELLMORE FACILITY/GRP
CT060669107OtherUBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY
CTPENDINGOtherAETNA BEHAVIORAL HEALTH
CT060669107OtherANTHEM BCBS OF CT WELLMORE GRP/FACILITY
CT060669107OtherUNITED BEHAVIORAL HEALTH WELLMORE GRP/FACILITY
CT060669107OtherUBH- OXFORD HEALTH/FREEDOM/LIBERTY WELLMORE GRP/FACILITY
CT13818169OtherCAQH
CT060669107OtherUBH-CONNECTICARE WELLMORE GRP/FACILITY
CTPENDINGOtherCIGNA BEHAVIORAL HEALTH
CTNOT ELIGIBLEOtherMHN TRICARENORTH
CTNOT ELIGIBLEOtherMHN TRICARENORTH