Provider Demographics
NPI:1902395650
Name:WALLACE, DANIEL (LMSW, LCSW)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LMSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2641 W CAMINO DEL VENEGAS
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-9287
Mailing Address - Country:US
Mailing Address - Phone:602-373-4672
Mailing Address - Fax:
Practice Address - Street 1:3601 S 6TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723-0001
Practice Address - Country:US
Practice Address - Phone:520-792-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IL149.0245181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical