Healthcare Provider Details

I. General information

NPI: 1982269155
Provider Name (Legal Business Name): DYLAN WALLACE LCSW, QCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MAIN STREET EXT STE 104
PLYMOUTH MA
02360-3375
US

IV. Provider business mailing address

1469 N 1200 W
OREM UT
84057-2449
US

V. Phone/Fax

Practice location:
  • Phone: 801-655-5450
  • Fax: 385-225-9327
Mailing address:
  • Phone: 801-655-5450
  • Fax: 385-225-9327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW15210
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-22060
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW126861
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW61224850
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11338410-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: