Provider Demographics
NPI:1508183831
Name:WALLACE, MARIA HEBERT (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:HEBERT
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 1:207 WAVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-8091
Mailing Address - Country:US
Mailing Address - Phone:337-281-1121
Mailing Address - Fax:
Practice Address - Street 1:345 DOUCET RD STE 228
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3490
Practice Address - Country:US
Practice Address - Phone:337-281-1121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA89561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical