Healthcare Provider Details

I. General information

NPI: 1811015597
Provider Name (Legal Business Name): KAREN ELYSE WALLACE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 W 97TH ST
LOS ANGELES CA
90003-3968
US

IV. Provider business mailing address

PO BOX 5708
GARDENA CA
90249-5708
US

V. Phone/Fax

Practice location:
  • Phone: 323-754-2856
  • Fax:
Mailing address:
  • Phone: 323-750-5167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 21147
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberLCS 21147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: