Provider Demographics
NPI:1811127947
Name:WALLACE, MARY VIRGINIA (LCSW, ACSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:VIRGINIA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9927 BURNHAM DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-2411
Mailing Address - Country:US
Mailing Address - Phone:469-442-6001
Mailing Address - Fax:469-330-6405
Practice Address - Street 1:1401 N CENTRAL EXPY
Practice Address - Street 2:SUITE 375
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-4669
Practice Address - Country:US
Practice Address - Phone:469-442-6001
Practice Address - Fax:972-231-9009
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX308611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical