Provider Demographics
NPI:1851572606
Name:WALLACE, CAMILLA (LCSW)
Entity Type:Individual
Prefix:
First Name:CAMILLA
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 1:1007 CHURCH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1007 CHURCH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3624
Practice Address - Country:US
Practice Address - Phone:847-492-1938
Practice Address - Fax:847-423-5670
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0133061041C0700X
MI68010933241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical