Healthcare Provider Details

I. General information

NPI: 1346824331
Provider Name (Legal Business Name): CASEY ANN WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 07/04/2024
Certification Date: 07/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 N SHERIDAN RD SUITE 809
CHICAGO IL
60657
US

IV. Provider business mailing address

3024 N LINCOLN AVE UNIT F
CHICAGO IL
60657-4253
US

V. Phone/Fax

Practice location:
  • Phone: 312-761-4721
  • Fax:
Mailing address:
  • Phone: 269-760-4020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149026886
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: