Healthcare Provider Details

I. General information

NPI: 1528107471
Provider Name (Legal Business Name): HEIDI ALLISON WILKEN WALLACE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEIDI ALLISON WILKEN LCSW

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27566 1375 EAST ST
WALNUT IL
61376-9528
US

IV. Provider business mailing address

27566 1375 EAST ST
WALNUT IL
61376-9528
US

V. Phone/Fax

Practice location:
  • Phone: 815-383-7277
  • Fax: 815-379-2184
Mailing address:
  • Phone: 815-383-7277
  • Fax: 815-379-2184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149012947
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License NumberHW49060306P
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: