Healthcare Provider Details

I. General information

NPI: 1184275802
Provider Name (Legal Business Name): MR. DERRICK PAUL WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 PROFESSIONAL HEIGHTS DR STE 240
LEXINGTON KY
40503-3040
US

IV. Provider business mailing address

2275 ROBINSON RENAKER RD
BERRY KY
41003-8521
US

V. Phone/Fax

Practice location:
  • Phone: 855-591-0092
  • Fax:
Mailing address:
  • Phone: 859-699-0090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: