Provider Demographics
NPI:1790239390
Name:WALLACE-BENNING, AMI E (LISW)
Entity Type:Individual
Prefix:
First Name:AMI
Middle Name:E
Last Name:WALLACE-BENNING
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45404-0549
Mailing Address - Country:US
Mailing Address - Phone:937-203-0975
Mailing Address - Fax:855-595-2759
Practice Address - Street 1:3331 STANLEY AVE STE A
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-2022
Practice Address - Country:US
Practice Address - Phone:937-203-0975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.16001771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0183087Medicaid