Healthcare Provider Details

I. General information

NPI: 1346962768
Provider Name (Legal Business Name): ANNISHA WALLACE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 E BASELINE RD STE 5
PHOENIX AZ
85042-6536
US

IV. Provider business mailing address

3101 N CENTRAL AVE STE 550
PHOENIX AZ
85012-2635
US

V. Phone/Fax

Practice location:
  • Phone: 602-230-7373
  • Fax: 602-441-5836
Mailing address:
  • Phone: 602-230-7373
  • Fax: 602-682-7455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-18807
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-21745
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: