Provider Demographics
NPI:1780040600
Name:WALLACE, CARLY (LCSW)
Entity Type:Individual
Prefix:
First Name:CARLY
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 1:21 BIDWELL SQ
Mailing Address - Street 2:
Mailing Address - City:UNIONVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06085-1115
Mailing Address - Country:US
Mailing Address - Phone:860-977-2324
Mailing Address - Fax:
Practice Address - Street 1:233 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-4204
Practice Address - Country:US
Practice Address - Phone:860-977-2324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT116551041C0700X
MA1207471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical