Provider Demographics
NPI:1295433167
Name:WALLACE, ANDREW NATHAN (LCSW)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:NATHAN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1193 WADE GREEN CIR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-3491
Mailing Address - Country:US
Mailing Address - Phone:770-866-6851
Mailing Address - Fax:
Practice Address - Street 1:191 LAMAR HALEY PKWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-8019
Practice Address - Country:US
Practice Address - Phone:770-704-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0084171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical