MEDICARE: CHRISTOPHER SCOTT WALLACE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	17443	MD
2	1041C0700X	Clinical Social Worker	0904009872	VA
3	1041C0700X	Clinical Social Worker	22821	AZ

General Provider Information

NPI Number	:	1366974610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER SCOTT WALLACE LCSW

Provider Business Mailing Address
First Line	:	101 N 1ST AVE STE 2325
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85003-1933
Country	:	US
Telephone Number	:	770-714-9847
Fax Number	:	757-953-6091

Provider Business Practice Location Address
First Line	:	101 N 1ST AVE STE 2325
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85003-1933
Country	:	US
Telephone Number	:	480-569-1604
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2017
Last Update Date	:	04/05/2025

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