Provider Demographics
NPI:1730968363
Name:WALLACE, JULIA LYNETTE (TEMPORARY CSW)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:LYNETTE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:TEMPORARY CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25640 LOUISVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42160-7729
Mailing Address - Country:US
Mailing Address - Phone:270-250-4733
Mailing Address - Fax:
Practice Address - Street 1:1175 CANE VALLEY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-9540
Practice Address - Country:US
Practice Address - Phone:270-384-6750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2584261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical