Provider Demographics
NPI:1841771292
Name:WALLACE, DANIEL (DSW)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22997 KRISTINE LN
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1273
Mailing Address - Country:US
Mailing Address - Phone:708-925-7022
Mailing Address - Fax:
Practice Address - Street 1:22997 KRISTINE LN
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1273
Practice Address - Country:US
Practice Address - Phone:708-925-7022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.106556104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILW42016193278Medicaid