Provider Demographics
NPI:1699042788
Name:WALLACE, BENNETT ALLAN (MSSW)
Entity Type:Individual
Prefix:MR
First Name:BENNETT
Middle Name:ALLAN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 E ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-1908
Mailing Address - Country:US
Mailing Address - Phone:502-693-2606
Mailing Address - Fax:
Practice Address - Street 1:164 E ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-1908
Practice Address - Country:US
Practice Address - Phone:502-693-2606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical