Provider Demographics
NPI:1659847721
Name:ASCENCIO, WALLACE ROBERTO (LICSW)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:ROBERTO
Last Name:ASCENCIO
Suffix:
Gender:
Credentials:LICSW
Other - Prefix:DR
Other - First Name:WALLACE
Other - Middle Name:ROBERT
Other - Last Name:ASCENCIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:7401 W HOOD PL STE 117
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-3400
Mailing Address - Country:US
Mailing Address - Phone:509-596-6230
Mailing Address - Fax:509-221-1455
Practice Address - Street 1:7401 W HOOD PL STE 117
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-3400
Practice Address - Country:US
Practice Address - Phone:509-596-6230
Practice Address - Fax:509-221-1455
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW612162811041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALW61216281OtherDEPARTMENT OF HEALTH
WA2206694Medicaid