Provider Demographics
NPI:1790818052
Name:WALLACE, ANNE (MSW)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 MOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VT
Mailing Address - Zip Code:05443-1307
Mailing Address - Country:US
Mailing Address - Phone:802-453-3840
Mailing Address - Fax:
Practice Address - Street 1:89 MAIN ST
Practice Address - Street 2:CSAC
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1459
Practice Address - Country:US
Practice Address - Phone:802-388-3171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-0000520104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker