Provider Demographics
NPI:1437590973
Name:WALLACE, JOHN BURTON V (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BURTON
Last Name:WALLACE
Suffix:V
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 1:1736 OAKVIEW RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-4235
Mailing Address - Country:US
Mailing Address - Phone:917-392-6700
Mailing Address - Fax:
Practice Address - Street 1:1123 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1207
Practice Address - Country:US
Practice Address - Phone:917-392-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker