Provider Demographics
NPI:1851631485
Name:WALLACE, WILLIE JAMES JR (LMSW)
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:JAMES
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 PRIDE DR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-9527
Mailing Address - Country:US
Mailing Address - Phone:985-543-4730
Mailing Address - Fax:985-543-4752
Practice Address - Street 1:835 PRIDE DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-9527
Practice Address - Country:US
Practice Address - Phone:985-543-4730
Practice Address - Fax:985-543-4752
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA48521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical