Provider Demographics
NPI:1902078033
Name:WALLACE, PAULA J (MSW,LAC)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSW,LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 15TH ST W
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-4155
Mailing Address - Country:US
Mailing Address - Phone:406-256-1434
Mailing Address - Fax:
Practice Address - Street 1:1250 15TH ST W
Practice Address - Street 2:SUITE 201
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-4155
Practice Address - Country:US
Practice Address - Phone:406-256-1434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT993101YA0400X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker