Provider Demographics
NPI:1942383427
Name:CARPENTER WALLACE, DEBORAH JEAN (LICSW)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JEAN
Last Name:CARPENTER WALLACE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 PARK ROAD 21
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-8561
Mailing Address - Country:US
Mailing Address - Phone:817-875-0144
Mailing Address - Fax:
Practice Address - Street 1:3 COURTHOUSE LANE SUITE 3
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824
Practice Address - Country:US
Practice Address - Phone:978-256-1444
Practice Address - Fax:978-441-1773
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1108231041C0700X
NV9859-C1041C0700X
TX505631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP23317Medicare ID - Type Unspecified