Healthcare Provider Details

I. General information

NPI: 1770420689
Provider Name (Legal Business Name): CIARA JACOLE WALLACE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 WARRENTON HWY STE A
THOMSON GA
30824-8061
US

IV. Provider business mailing address

225 CROWN HEIGHTS WAY
GROVETOWN GA
30813-5906
US

V. Phone/Fax

Practice location:
  • Phone: 706-496-5929
  • Fax:
Mailing address:
  • Phone: 706-496-5929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMSW012953
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: