Provider Demographics
NPI:1184275802
Name:WALLACE, DERRICK PAUL
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:PAUL
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 ROBINSON RENAKER RD
Mailing Address - Street 2:
Mailing Address - City:BERRY
Mailing Address - State:KY
Mailing Address - Zip Code:41003-8521
Mailing Address - Country:US
Mailing Address - Phone:859-699-0090
Mailing Address - Fax:
Practice Address - Street 1:2375 PROFESSIONAL HEIGHTS DR STE 240
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3040
Practice Address - Country:US
Practice Address - Phone:855-591-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical