Healthcare Provider Details

I. General information

NPI: 1952488124
Provider Name (Legal Business Name): SHAROLYN JAN WALLACE PHD, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 E SKELLY DR
TULSA OK
74105-6317
US

IV. Provider business mailing address

PO BOX 27451
TULSA OK
74149-0451
US

V. Phone/Fax

Practice location:
  • Phone: 918-665-0208
  • Fax: 918-665-0216
Mailing address:
  • Phone: 918-639-4574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1803-LCSW
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: