Provider Demographics
NPI:1659847721
Name:ASCENCIO, WALLACE ROBERTO (LICSW)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:ROBERTO
Last Name:ASCENCIO
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:MR
Other - First Name:WALLACE
Other - Middle Name:ROBERT
Other - Last Name:ASCENCIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:8797 W GAGE BLVD STE C203
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7194
Mailing Address - Country:US
Mailing Address - Phone:509-596-6230
Mailing Address - Fax:509-783-7269
Practice Address - Street 1:8797 W GAGE BLVD STE C203
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7194
Practice Address - Country:US
Practice Address - Phone:509-596-6230
Practice Address - Fax:509-783-7269
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2022-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC608667461041C0700X
WALW612162811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2206694Medicaid
WALW61216281OtherDEPARTMENT OF HEALTH