Provider Demographics
NPI:1386517050
Name:WALLACE, DEBRA (LMSW)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMSW
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 411
Mailing Address - Street 2:
Mailing Address - City:NORTH CHILI
Mailing Address - State:NY
Mailing Address - Zip Code:14514-0411
Mailing Address - Country:US
Mailing Address - Phone:585-261-9059
Mailing Address - Fax:
Practice Address - Street 1:1100 LONG POND RD
Practice Address - Street 2:
Practice Address - City:GREECE
Practice Address - State:NY
Practice Address - Zip Code:14626-1177
Practice Address - Country:US
Practice Address - Phone:585-385-6030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-27
Last Update Date:2025-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127173-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker