Healthcare Provider Details

I. General information

NPI: 1427668102
Provider Name (Legal Business Name): STEPHEN WALLACE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 NE 83RD ST
KANSAS CITY MO
64119-4400
US

IV. Provider business mailing address

3100 NE 83RD ST
KANSAS CITY MO
64119-4400
US

V. Phone/Fax

Practice location:
  • Phone: 816-468-0400
  • Fax:
Mailing address:
  • Phone: 816-468-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2024019009
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: