Healthcare Provider Details

I. General information

NPI: 1831023357
Provider Name (Legal Business Name): MICHELLE MCCOY WALLACE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 PARK FOREST DR
HURST TX
76053-7100
US

IV. Provider business mailing address

812 PARK FOREST DR
HURST TX
76053-7100
US

V. Phone/Fax

Practice location:
  • Phone: 817-929-3714
  • Fax:
Mailing address:
  • Phone: 817-929-3714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number27809
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: