Provider Demographics
NPI:1730511916
Name:WALLACE, HEIDI L (LSW, CDCA)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LSW, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 BOWTOWN RD
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-9661
Mailing Address - Country:US
Mailing Address - Phone:740-369-7688
Mailing Address - Fax:740-363-6415
Practice Address - Street 1:824 BOWTOWN RD
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-9661
Practice Address - Country:US
Practice Address - Phone:740-369-7688
Practice Address - Fax:740-363-6415
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.12015131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical