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General NPI Number Information
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NPI Number | 1528107471
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Entity Type | Individual
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Provider Name | HEIDI ALLISON WILKEN WALLACE LCSW
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Gender | Female
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 11/19/2012
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Provider Practice Location Address
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Address Line | 27566 1375 EAST ST
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City | WALNUT
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State | IL
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Zip | 61376-9528
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Country | US
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Telephone | 815-383-7277
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Fax | 815-379-2184
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Provider Business Mailing Address
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Address Line | 27566 1375 EAST ST
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City | WALNUT
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State | IL
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Zip | 61376-9528
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Country | US
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Telephone | 815-383-7277
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Fax | 815-379-2184
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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 | 149012947
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 222Q00000X
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Taxonomy Name | Developmental Therapist
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License Number | HW49060306P
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License Number State | IL
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