Provider Demographics
NPI:1619513405
Name:BELLIS, WALLACE E (LCSW)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:E
Last Name:BELLIS
Suffix:
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 1:138 LEADER AVE STE 129D
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-3215
Mailing Address - Country:US
Mailing Address - Phone:859-218-6727
Mailing Address - Fax:859-257-1888
Practice Address - Street 1:138 LEADER AVE STE 129D
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-3215
Practice Address - Country:US
Practice Address - Phone:859-218-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2540871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical