Provider Demographics
NPI:1306293659
Name:WALLACE, TAVIA (MSW, LGSW)
Entity type:Individual
Prefix:
First Name:TAVIA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:TAVIA
Other - Middle Name:
Other - Last Name:ELDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2121 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-3803
Mailing Address - Country:US
Mailing Address - Phone:304-485-1721
Mailing Address - Fax:
Practice Address - Street 1:2121 7TH ST
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-3803
Practice Address - Country:US
Practice Address - Phone:304-485-1721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00947323104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1386795516Medicaid