Provider Demographics
NPI:1548692189
Name:WALLACE, COURTNEY CREAL (LCSW, CADC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:CREAL
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 S SHELBY ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1107
Mailing Address - Country:US
Mailing Address - Phone:502-635-4538
Mailing Address - Fax:502-635-4570
Practice Address - Street 1:1432 S SHELBY ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1166
Practice Address - Country:US
Practice Address - Phone:502-635-4538
Practice Address - Fax:502-635-4570
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1771101YA0400X
KY38821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)