Provider Demographics
NPI:1619104742
Name:WALLACE, RACHAEL (LCSW)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:
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 1:419 W REDWOOD ST
Mailing Address - Street 2:SUITE 570
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1734
Mailing Address - Country:US
Mailing Address - Phone:410-328-6106
Mailing Address - Fax:410-328-1130
Practice Address - Street 1:419 W REDWOOD ST
Practice Address - Street 2:SUITE 570
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1734
Practice Address - Country:US
Practice Address - Phone:410-328-6106
Practice Address - Fax:410-328-1130
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD150761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD601 LMedicare UPIN