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General NPI Number Information
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NPI Number | 1366974610
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Entity Type | Individual
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Provider Name | CHRISTOPHER SCOTT WALLACE LCSW
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Gender | Male
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Dates
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Enumeration Date | 03/28/2017
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Last Update Date | 04/05/2025
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Provider Practice Location Address
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Address Line | 101 N 1ST AVE STE 2325
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City | PHOENIX
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State | AZ
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Zip | 85003-1933
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Country | US
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Telephone | 480-569-1604
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Fax |
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Provider Business Mailing Address
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Address Line | 101 N 1ST AVE STE 2325
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City | PHOENIX
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State | AZ
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Zip | 85003-1933
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Country | US
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Telephone | 770-714-9847
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Fax | 757-953-6091
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 17443
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0904009872
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 22821
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License Number State | AZ
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