Provider Demographics
NPI:1427870799
Name:WALLACE, COURTNEY (APSW)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:APSW
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:BECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APSW
Mailing Address - Street 1:620 S 76TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-1599
Mailing Address - Country:US
Mailing Address - Phone:414-292-4242
Mailing Address - Fax:414-453-2538
Practice Address - Street 1:620 S 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-1599
Practice Address - Country:US
Practice Address - Phone:414-292-4242
Practice Address - Fax:414-453-2538
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI134408104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker