Provider Demographics
NPI:1891041166
Name:WALLACE, DANNA KAYE (MSW, CSW, CABIP)
Entity Type:Individual
Prefix:
First Name:DANNA
Middle Name:KAYE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSW, CSW, CABIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2367
Mailing Address - Country:US
Mailing Address - Phone:270-904-0201
Mailing Address - Fax:270-904-0221
Practice Address - Street 1:730 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2367
Practice Address - Country:US
Practice Address - Phone:270-904-0201
Practice Address - Fax:270-904-0221
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY05202012101YA0400X, 101YM0800X
05202012101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health