Provider Demographics
NPI:1932610623
Name:WALLACE, LOWELL
Entity Type:Individual
Prefix:
First Name:LOWELL
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 E MAIN ST STE 24
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-2300
Mailing Address - Country:US
Mailing Address - Phone:601-781-8677
Mailing Address - Fax:601-207-7720
Practice Address - Street 1:1120 E MAIN ST STE 24
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-2300
Practice Address - Country:US
Practice Address - Phone:601-781-8677
Practice Address - Fax:601-207-7720
Is Sole Proprietor?:No
Enumeration Date:2017-10-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical