Provider Demographics
NPI:1598819989
Name:WALLACE, DARLENE J (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:DARLENE
Middle Name:J
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 1:6800 N WAUKESHA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-1528
Mailing Address - Country:US
Mailing Address - Phone:773-775-0097
Mailing Address - Fax:847-413-0429
Practice Address - Street 1:1701 E WOODFIELD RD
Practice Address - Street 2:SUITE 321
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173
Practice Address - Country:US
Practice Address - Phone:773-775-0097
Practice Address - Fax:847-413-0429
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01671233OtherBLUE CROSS OF IL