Healthcare Provider Details

I. General information

NPI: 1225587736
Provider Name (Legal Business Name): CAROLINE WALLACE MSW, LCSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 UNION ST STE 201
EASTHAMPTON MA
01027-4100
US

IV. Provider business mailing address

123 UNION ST STE 201
EASTHAMPTON MA
01027-4100
US

V. Phone/Fax

Practice location:
  • Phone: 413-206-9172
  • Fax:
Mailing address:
  • Phone: 413-206-9172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number122644
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: