Provider Demographics
NPI:1700110764
Name:WALLACE, MARGARET ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARGARET
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8626 AIRWAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-2603
Mailing Address - Country:US
Mailing Address - Phone:662-772-5937
Mailing Address - Fax:662-772-5940
Practice Address - Street 1:8626 AIRWAYS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-2603
Practice Address - Country:US
Practice Address - Phone:662-772-5937
Practice Address - Fax:662-772-5940
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC76631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical