Provider Demographics
NPI:1952488124
Name:WALLACE, SHAROLYN JAN (PHD, LCSW)
Entity Type:Individual
Prefix:
First Name:SHAROLYN
Middle Name:JAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27451
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74149-0451
Mailing Address - Country:US
Mailing Address - Phone:918-639-4574
Mailing Address - Fax:
Practice Address - Street 1:3015 E SKELLY DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6317
Practice Address - Country:US
Practice Address - Phone:918-665-0208
Practice Address - Fax:918-665-0216
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1803-LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical